Healthcare Provider Details

I. General information

NPI: 1104222660
Provider Name (Legal Business Name): COLETTE VASSILIAN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2014
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 SAINT ALPHONSUS WAY
ALAMO CA
94507-1570
US

IV. Provider business mailing address

1450 TREAT BLVD STE 300
WALNUT CREEK CA
94597-2168
US

V. Phone/Fax

Practice location:
  • Phone: 925-838-4633
  • Fax:
Mailing address:
  • Phone: 925-952-2828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A14283
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: