Healthcare Provider Details

I. General information

NPI: 1740982487
Provider Name (Legal Business Name): PETER ANTHONY VASALLO III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1580 SANTA BARBARA BLVD
THE VILLAGES FL
32159-6827
US

IV. Provider business mailing address

1580 SANTA BARBARA BLVD
THE VILLAGES FL
32159-6827
US

V. Phone/Fax

Practice location:
  • Phone: 352-259-2159
  • Fax: 352-259-5731
Mailing address:
  • Phone: 352-259-2159
  • Fax: 352-259-5731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME180364
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: