Basic Information
| Provider Information | |||||||||
| NPI: | 1467560094 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WASSERSTEIN | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1615 HILL RD | ||||||||
| Address2: | STE B | ||||||||
| City: | NOVATO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158987649 | ||||||||
| FaxNumber: | 4158980870 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 BON AIR RD | ||||||||
| Address2: | |||||||||
| City: | GREENBRAE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159257174 | ||||||||
| FaxNumber: | 4158980870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 07/12/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207U00000X | G358910 | CA | N | Allopathic & Osteopathic Physicians | Nuclear Medicine | 207ZP0102X | G358910 | CA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 00G358910 | 05 | CA | MEDICAID |