Healthcare Provider Details

I. General information

NPI: 1861498560
Provider Name (Legal Business Name): PASQUALE D VASSALLUZZO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: P D VASSALLUZZO MD

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78 VIRGINIA DR
ATCO NJ
08004-2828
US

IV. Provider business mailing address

78 VIRGINIA DR
ATCO NJ
08004-2828
US

V. Phone/Fax

Practice location:
  • Phone: 856-336-2842
  • Fax:
Mailing address:
  • Phone: 856-336-2842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number25MA03395100
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberMD036800L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: