Basic Information
| Provider Information | |||||||||
| NPI: | 1225281470 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VASSALLO | ||||||||
| FirstName: | SHERYL | ||||||||
| MiddleName: | LISA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 416457 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022411735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8443621735 | ||||||||
| FaxNumber: | 9732907495 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 NEW PROVIDENCE RD | ||||||||
| Address2: | |||||||||
| City: | MOUNTAINSIDE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070922590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082333720 | ||||||||
| FaxNumber: | 9083015430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2008 | ||||||||
| LastUpdateDate: | 11/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 25MA08431000 | NJ | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080H0002X | 25MA08431000 | NJ | Y | Allopathic & Osteopathic Physicians | Pediatrics | Hospice and Palliative Medicine |
No ID Information.