Basic Information
| Provider Information | |||||||||
| NPI: | 1053380584 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VASSILENKO | ||||||||
| FirstName: | MIKHAIL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1065 NE 125TH ST | ||||||||
| Address2: | STE 300 | ||||||||
| City: | NORTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331615833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888526672 | ||||||||
| FaxNumber: | 3058914228 | ||||||||
| Practice Location | |||||||||
| Address1: | 10301 HAGEN RANCH RD | ||||||||
| Address2: | STE B6 | ||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334373723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617529490 | ||||||||
| FaxNumber: | 5617529491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 07/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MD062001L | PA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | ME156021 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 114812600 | 05 | FL | MEDICAID |