Provider Demographics
NPI:1295720050
Name:VASSANTACHART, PRASERT BASIL (MD)
Entity type:Individual
Prefix:DR
First Name:PRASERT
Middle Name:BASIL
Last Name:VASSANTACHART
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:BASIL
Other - Middle Name:P
Other - Last Name:VASSANTACHART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:841 W VALLEY BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-3251
Mailing Address - Country:US
Mailing Address - Phone:626-282-3113
Mailing Address - Fax:626-289-9179
Practice Address - Street 1:841 W VALLEY BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803-3251
Practice Address - Country:US
Practice Address - Phone:626-282-3113
Practice Address - Fax:626-289-9179
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44008208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G440080Medicaid
CAWG44D08AMedicare ID - Type Unspecified
CA00G440080Medicaid