Provider Demographics
NPI:1861498560
Name:VASSALLUZZO, PASQUALE D (MD)
Entity Type:Individual
Prefix:DR
First Name:PASQUALE
Middle Name:D
Last Name:VASSALLUZZO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:P
Other - Middle Name:D
Other - Last Name:VASSALLUZZO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:78 VIRGINIA DR
Mailing Address - Street 2:
Mailing Address - City:ATCO
Mailing Address - State:NJ
Mailing Address - Zip Code:08004-2828
Mailing Address - Country:US
Mailing Address - Phone:856-336-2842
Mailing Address - Fax:
Practice Address - Street 1:78 VIRGINIA DR
Practice Address - Street 2:
Practice Address - City:ATCO
Practice Address - State:NJ
Practice Address - Zip Code:08004-2828
Practice Address - Country:US
Practice Address - Phone:856-336-2842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03395100207QA0505X
PAMD036800L207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA126753OtherBLUE CROSS BLUE SHIELD
PA126753OtherPERSONAL CHOICE
PA126753OtherPERSONAL CHOICE
PA126753OtherBLUE CROSS BLUE SHIELD