Provider Demographics
NPI:1992749071
Name:VLASAK, JERRY WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:WILLIAM
Last Name:VLASAK
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 1:556 S FAIR OAKS AVE
Mailing Address - Street 2:SUITE 101, #25
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2656
Mailing Address - Country:US
Mailing Address - Phone:310-251-0259
Mailing Address - Fax:213-477-2306
Practice Address - Street 1:100 W CALIFORNIA BLVD
Practice Address - Street 2:TRAUMA SERVICES
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3010
Practice Address - Country:US
Practice Address - Phone:310-251-0259
Practice Address - Fax:213-477-2306
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2013-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA042683208600000X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABY235AMedicare PIN