Provider Demographics
NPI:1215169396
Name:VICTOR M. WASSILY, M.D. INC.
Entity type:Organization
Organization Name:VICTOR M. WASSILY, M.D. INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:M
Authorized Official - Last Name:WASSILY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-722-7711
Mailing Address - Street 1:111 W BEVERLY BLVD STE 217
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4320
Mailing Address - Country:US
Mailing Address - Phone:323-722-7711
Mailing Address - Fax:323-722-7127
Practice Address - Street 1:111 W BEVERLY BLVD STE 217
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4320
Practice Address - Country:US
Practice Address - Phone:323-722-7711
Practice Address - Fax:323-722-7127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-21
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53474207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG37810Medicare UPIN