Provider Demographics
NPI:1609834324
Name:VASSILIEV, DMITRI (MD)
Entity Type:Individual
Prefix:
First Name:DMITRI
Middle Name:
Last Name:VASSILIEV
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 1:12311 PERRY HWY
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-8344
Mailing Address - Country:US
Mailing Address - Phone:878-332-4242
Mailing Address - Fax:878-332-4485
Practice Address - Street 1:12311 PERRY HWY
Practice Address - Street 2:
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-8344
Practice Address - Country:US
Practice Address - Phone:878-332-4242
Practice Address - Fax:878-332-4485
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD067796L207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001843481Medicaid
10938106OtherCAQH