Healthcare Provider Details

I. General information

NPI: 1730359043
Provider Name (Legal Business Name): VASSALLO EYE INSTITUTE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2008
Last Update Date: 03/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3780 US HIGHWAY 1 S
ST AUGUSTINE FL
32086-7150
US

IV. Provider business mailing address

PO BOX 1598
ST AUGUSTINE FL
32085-1598
US

V. Phone/Fax

Practice location:
  • Phone: 904-797-7722
  • Fax:
Mailing address:
  • Phone: 904-797-7722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME59092
License Number StateFL

VIII. Authorized Official

Name: JOHN M VASSALLO
Title or Position: OWNER
Credential: MD
Phone: 904-797-7722