MEDICARE: DR. EDWARD ROBERT WASSMAN JR. M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207SC0300X	Clinical Cytogenetics Physician	135000	NY
2	207SC0300X	Clinical Cytogenetics Physician	DRNM10	CA
3	207SG0201X	Clinical Genetics (M.D.) Physician	G040633	CA
4	207SG0201X	Clinical Genetics (M.D.) Physician	41719	CT
5	207SG0201X	Clinical Genetics (M.D.) Physician	ME80666	FL
6	208000000X	Pediatrics Physician	30741	AZ
7	207SG0203X	Clinical Molecular Genetics Physician	DRN2	CA

General Provider Information

NPI Number	:	1396966735
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDWARD ROBERT WASSMAN JR. M.D.

Provider Business Mailing Address
First Line	:	7482 PINEBROOK RD
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098-5346
Country	:	US
Telephone Number	:	562-500-5197
Fax Number	:

Provider Business Practice Location Address
First Line	:	7482 PINEBROOK RD
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098-5346
Country	:	US
Telephone Number	:	562-500-5197
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	08/10/2022

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