Provider Demographics
NPI:1962423590
Name:WASSILY, VICTOR M (MD)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:M
Last Name:WASSILY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:101 E BEVERLY BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4315
Mailing Address - Country:US
Mailing Address - Phone:323-722-7711
Mailing Address - Fax:323-722-7127
Practice Address - Street 1:101 E BEVERLY BLVD STE 202
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4315
Practice Address - Country:US
Practice Address - Phone:323-722-7711
Practice Address - Fax:323-722-7127
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA53474207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A534740Medicaid
CAG37810Medicare UPIN
CAA53474AMedicare ID - Type Unspecified