Provider Demographics
NPI:1396966735
Name:WASSMAN, EDWARD ROBERT JR (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:ROBERT
Last Name:WASSMAN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7482 PINEBROOK RD
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-5346
Mailing Address - Country:US
Mailing Address - Phone:562-500-5197
Mailing Address - Fax:
Practice Address - Street 1:7482 PINEBROOK RD
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-5346
Practice Address - Country:US
Practice Address - Phone:562-500-5197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY135000207SC0300X
CADRNM10207SC0300X
CAG040633207SG0201X
CT41719207SG0201X
FLME80666207SG0201X
AZ30741208000000X
CADRN2207SG0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0203XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Molecular Genetics
No207SC0300XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Cytogenetics
No207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE91615Medicare UPIN