Provider Demographics
NPI:1922393008
Name:WASSERMAN, COREY ILYSSA (MD)
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:ILYSSA
Last Name:WASSERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:COREY
Other - Middle Name:ILYSSA
Other - Last Name:WAXMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:40 WORTH ST
Mailing Address - Street 2:SUITE 402
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-2904
Mailing Address - Country:US
Mailing Address - Phone:646-962-3400
Mailing Address - Fax:
Practice Address - Street 1:40 WORTH ST
Practice Address - Street 2:SUITE 402
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-2904
Practice Address - Country:US
Practice Address - Phone:646-962-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-16
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY271434208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics