Provider Demographics
NPI:1639348014
Name:VASELICH, SAMUEL JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:JOHN
Last Name:VASELICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2602 ISAAC DR
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-8117
Mailing Address - Country:US
Mailing Address - Phone:703-965-8088
Mailing Address - Fax:
Practice Address - Street 1:2602 ISAAC DR
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530-8117
Practice Address - Country:US
Practice Address - Phone:703-965-8088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-29
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVSL0535174400000X
VA0102202255208D00000X
NC201500496207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No174400000XOther Service ProvidersSpecialist
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice