Provider Demographics
NPI:1457140824
Name:VASSALLO BEDOYA, MAURICIO (MD)
Entity type:Individual
Prefix:
First Name:MAURICIO
Middle Name:
Last Name:VASSALLO BEDOYA
Suffix:
Gender:
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:AV. MANUEL OLGUIN 1053 CASA B1
Mailing Address - Street 2:
Mailing Address - City:SANTIAGO DE SURCO
Mailing Address - State:LIMA
Mailing Address - Zip Code:15023
Mailing Address - Country:PE
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:AV ANGAMOS ESTE 2688
Practice Address - Street 2:
Practice Address - City:SURQUILLO
Practice Address - State:LIMA
Practice Address - Zip Code:15038
Practice Address - Country:PE
Practice Address - Phone:718-579-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-02
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program