Healthcare Provider Details

I. General information

NPI: 1205869849
Provider Name (Legal Business Name): ERNEST JOSEPH VASTI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 11/05/2020
Certification Date: 11/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10089 FOLSOM BLVD, SUITES A & C
RANCHO CORDOVA CA
95670-1935
US

IV. Provider business mailing address

PO BOX 4057
STOCKTON CA
95204
US

V. Phone/Fax

Practice location:
  • Phone: 916-366-6531
  • Fax:
Mailing address:
  • Phone: 209-463-0891
  • Fax: 209-463-0560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberG54133
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: