Healthcare Provider Details

I. General information

NPI: 1790079804
Provider Name (Legal Business Name): LAUREN MARIE VASTA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2011
Last Update Date: 08/10/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 WISCONSIN AVE RM 4340
BETHESDA MD
20889-0004
US

IV. Provider business mailing address

8901 WISCONSIN AVE RM 4340
BETHESDA MD
20889-0004
US

V. Phone/Fax

Practice location:
  • Phone: 301-400-1663
  • Fax: 301-400-1662
Mailing address:
  • Phone: 301-319-1663
  • Fax: 301-319-1662

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101252374
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number0101252374
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: