1063288918 NPI number — DR. CAMILA ISABEL VASSALLO VISSEPO SR.

Table of content: DR. CAMILA ISABEL VASSALLO VISSEPO SR. (NPI 1063288918)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063288918 NPI number — DR. CAMILA ISABEL VASSALLO VISSEPO SR.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VASSALLO VISSEPO
Provider First Name:
CAMILA
Provider Middle Name:
ISABEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
SR.
Provider Credential Text:
Provider Gender Code:
F

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:
1063288918
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
URB TERRALINDA
Provider Second Line Business Mailing Address:
#8 CALLE CORDOVA
Provider Business Mailing Address City Name:
CAGUAS
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00727-2517
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-633-1190
Provider Business Mailing Address Fax Number:
787-746-5433

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
URB HYDE PARK 285 AVE JESUS T PINERO
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN JUAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00926-3901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-436-5595
Provider Business Practice Location Address Fax Number:
787-746-5433
Provider Enumeration Date:
12/01/2023

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:  960 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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