Provider Demographics
NPI:1255370797
Name:DIMASSA, GIANCARLO PASQUALE (MD)
Entity type:Individual
Prefix:
First Name:GIANCARLO
Middle Name:PASQUALE
Last Name:DIMASSA
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 1:817 S MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-4404
Mailing Address - Country:US
Mailing Address - Phone:310-753-0885
Mailing Address - Fax:626-696-3210
Practice Address - Street 1:817 S MADISON AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-4404
Practice Address - Country:US
Practice Address - Phone:310-753-0885
Practice Address - Fax:626-696-3210
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81063207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A810630OtherBLUE SHIELD
CA00A810630Medicaid
CA00A810630OtherBLUE SHIELD
CAI06516Medicare UPIN