Provider Demographics
NPI:1871656009
Name:PETER VASSALLUZZO D.O.
Entity Type:Organization
Organization Name:PETER VASSALLUZZO D.O.
Other - Org Name:LAWNDALE MEDICAL ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:VASSALLUZZO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:215-725-8111
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-006575L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0543451000OtherKEYSTONE
PA707562Medicare ID - Type Unspecified
PA0543451000OtherKEYSTONE