Provider Demographics
NPI:1770041063
Name:WASSERMAN, MAX
Entity Type:Individual
Prefix:
First Name:MAX
Middle Name:
Last Name:WASSERMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 SLOCUM AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-2253
Mailing Address - Country:US
Mailing Address - Phone:314-550-5866
Mailing Address - Fax:
Practice Address - Street 1:123 SLOCUM AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-2253
Practice Address - Country:US
Practice Address - Phone:314-550-5866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program