Provider Demographics
NPI:1619122041
Name:E MIKE VASILOMANOLAKIS M D INC
Entity Type:Organization
Organization Name:E MIKE VASILOMANOLAKIS M D INC
Other - Org Name:EMMANUEL M VASILOMANOLAKIS MD
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:CONSTANTINE
Authorized Official - Last Name:VASILOMANOLAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-494-3547
Mailing Address - Street 1:1760 TERMINO AVE
Mailing Address - Street 2:SUTE 314
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-2105
Mailing Address - Country:US
Mailing Address - Phone:562-494-3547
Mailing Address - Fax:
Practice Address - Street 1:1760 TERMINO AVE
Practice Address - Street 2:SUTE 314
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-2105
Practice Address - Country:US
Practice Address - Phone:562-494-3547
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-26
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41023207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G410230Medicaid
CA00G410230Medicaid
CAA48436Medicare UPIN