Provider Demographics
NPI:1750311148
Name:VASSALLUZZO, PETER (DO)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:VASSALLUZZO
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 1:6190 RISING SUN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-6011
Mailing Address - Country:US
Mailing Address - Phone:215-725-8111
Mailing Address - Fax:215-742-9501
Practice Address - Street 1:6190 RISING SUN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-6011
Practice Address - Country:US
Practice Address - Phone:215-725-8111
Practice Address - Fax:215-742-9501
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006575L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0543451001OtherBLUE SHIELD
PA1152OtherAETNA
PA707562OtherHIGHMARK
PA707562OtherHIGHMARK
PA0543451001OtherBLUE SHIELD