Provider Demographics
NPI:1710970447
Name:VASSALLO, SUSI (MD)
Entity Type:Individual
Prefix:
First Name:SUSI
Middle Name:
Last Name:VASSALLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-6402
Mailing Address - Country:US
Mailing Address - Phone:212-263-3293
Mailing Address - Fax:
Practice Address - Street 1:550 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-3293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY170778207L00000X, 207P00000X, 207PT0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical Toxicology
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY665V01Medicare ID - Type Unspecified
NYE56312Medicare UPIN