Provider Demographics
NPI:1417999038
Name:VASILYEVA, IRINA A (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:IRINA
Middle Name:A
Last Name:VASILYEVA
Suffix:
Gender:F
Credentials:MD PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:250 GORGE RD #8C
Mailing Address - Street 2:
Mailing Address - City:CLIFFSIDE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07010
Mailing Address - Country:US
Mailing Address - Phone:201-724-8178
Mailing Address - Fax:201-917-3447
Practice Address - Street 1:1001 POTRERO AVE
Practice Address - Street 2:RM 1X55
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3518
Practice Address - Country:US
Practice Address - Phone:415-206-5871
Practice Address - Fax:415-206-4004
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2017-09-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY2454452085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A925040Medicaid
I43056Medicare UPIN
CA00A925040Medicare ID - Type Unspecified