Provider Demographics
NPI:1538690995
Name:VASSAR, CODIE JORDAN (MD)
Entity Type:Individual
Prefix:DR
First Name:CODIE
Middle Name:JORDAN
Last Name:VASSAR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1282 E HICKORY CREEK CT
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-7316
Mailing Address - Country:US
Mailing Address - Phone:414-690-0069
Mailing Address - Fax:
Practice Address - Street 1:122 WILSHIRE BLVD N
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-1360
Practice Address - Country:US
Practice Address - Phone:715-341-7441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361591952084P0800X
WIT89672084P0800X
WI6978320208D00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice