Provider Demographics
NPI:1205922499
Name:VASSALLO, KEITH D (MD)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:D
Last Name:VASSALLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11511 SHADOW CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7298
Mailing Address - Country:US
Mailing Address - Phone:713-442-0000
Mailing Address - Fax:
Practice Address - Street 1:8233 N SAM HOUSTON PKWY E
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77396
Practice Address - Country:US
Practice Address - Phone:713-442-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5059207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX151834204Medicaid
TX151834201Medicaid
TX151834203Medicaid
TX151834202Medicaid
TX8920B9Medicare PIN
TX151834201Medicaid
TX8310B7Medicare PIN
TX151834203Medicaid