Healthcare Provider Details

I. General information

NPI: 1396966735
Provider Name (Legal Business Name): EDWARD ROBERT WASSMAN JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 08/10/2022
Certification Date: 08/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7482 PINEBROOK RD
PARK CITY UT
84098-5346
US

IV. Provider business mailing address

7482 PINEBROOK RD
PARK CITY UT
84098-5346
US

V. Phone/Fax

Practice location:
  • Phone: 562-500-5197
  • Fax:
Mailing address:
  • Phone: 562-500-5197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SC0300X
TaxonomyClinical Cytogenetics Physician
License Number135000
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207SC0300X
TaxonomyClinical Cytogenetics Physician
License NumberDRNM10
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberG040633
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number41719
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License NumberME80666
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number30741
License Number StateAZ
# 7
Primary TaxonomyY
Taxonomy Code207SG0203X
TaxonomyClinical Molecular Genetics Physician
License NumberDRN2
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: