Provider Demographics
NPI:1699701011
Name:WASSERMAN, PAUL LOUIS (DO)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:LOUIS
Last Name:WASSERMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MEMORIAL MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-5980
Mailing Address - Country:US
Mailing Address - Phone:386-586-2000
Mailing Address - Fax:317-705-5047
Practice Address - Street 1:60 MEMORIAL MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-5980
Practice Address - Country:US
Practice Address - Phone:386-586-2000
Practice Address - Fax:317-705-5047
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004-002782085B0100X, 2085R0202X, 2085R0204X
FLOS11132085B0100X
FLOS111132085R0204X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
189353OtherMEDCOST
NC2038722DOtherMEDICARE
7547722OtherAETNA
SCQ0027MMedicaid
805973OtherPARTNERS
NC5901625Medicaid
139NMOtherBCBS
WV3810008229Medicaid
P00367349OtherRR MEDICARE
WV3810008229Medicaid