1992712541 NPI number — VASELES ASIMACOPOULOS

Table of content: VASELES ASIMACOPOULOS (NPI 1992712541)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992712541 NPI number — VASELES ASIMACOPOULOS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ASIMACOPOULOS
Provider First Name:
VASELES
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992712541
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12200 AMOS LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREDERICKSBURG
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22407-7107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-786-4882
Provider Business Mailing Address Fax Number:
540-786-4893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5705 SALEM RUN BLVD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
FREDERICKSBURG
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22407-7119
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-726-4882
Provider Business Practice Location Address Fax Number:
540-786-4893
Provider Enumeration Date:
08/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  0104555602 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0104555602 . This is a "VA STATE LICENSE NUMBER" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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