Provider Demographics
NPI:1285708404
Name:VASSALLO, RICHARD W (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:VASSALLO
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 1:2701 HOLME AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-2029
Mailing Address - Country:US
Mailing Address - Phone:215-335-4944
Mailing Address - Fax:215-331-3619
Practice Address - Street 1:2701 HOLME AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-2029
Practice Address - Country:US
Practice Address - Phone:215-335-4944
Practice Address - Fax:215-331-3619
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAFMD011148E207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA031870Medicare ID - Type Unspecified
PAB33786Medicare UPIN