Basic Information
| Provider Information | |||||||||
| NPI: | 1609834324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VASSILIEV | ||||||||
| FirstName: | DMITRI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 12311 PERRY HWY | ||||||||
| Address2: | |||||||||
| City: | WEXFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150908344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8783324242 | ||||||||
| FaxNumber: | 8783324485 | ||||||||
| Practice Location | |||||||||
| Address1: | 12311 PERRY HWY | ||||||||
| Address2: | |||||||||
| City: | WEXFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150908344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8783324242 | ||||||||
| FaxNumber: | 8783324485 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 12/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | MD067796L | PA | Y | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001843481 | 05 | PA | MEDICAID | 10938106 | 01 | CAQH | OTHER |