Healthcare Provider Details

I. General information

NPI: 1992749071
Provider Name (Legal Business Name): JERRY WILLIAM VLASAK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 12/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W CALIFORNIA BLVD TRAUMA SERVICES
PASADENA CA
91105-3010
US

IV. Provider business mailing address

556 S FAIR OAKS AVE SUITE 101, #25
PASADENA CA
91105-2656
US

V. Phone/Fax

Practice location:
  • Phone: 310-251-0259
  • Fax: 213-477-2306
Mailing address:
  • Phone: 310-251-0259
  • Fax: 213-477-2306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA042683
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberA042683
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: