Healthcare Provider Details

I. General information

NPI: 1730170143
Provider Name (Legal Business Name): VINCENT MASSULLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2540 EAST ST
CONCORD CA
94520-1906
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 209-342-2300
  • Fax: 209-524-4240
Mailing address:
  • Phone: 925-952-2828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberG50723
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: