Basic Information
| Provider Information | |||||||||
| NPI: | 1699701011 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WASSERMAN | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | LOUIS | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 60 MEMORIAL MEDICAL PKWY | ||||||||
| Address2: | |||||||||
| City: | PALM COAST | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321645980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3865862000 | ||||||||
| FaxNumber: | 3177055047 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 MEMORIAL MEDICAL PKWY | ||||||||
| Address2: | |||||||||
| City: | PALM COAST | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321645980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3865862000 | ||||||||
| FaxNumber: | 3177055047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 09/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085B0100X | 2004-00278 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085B0100X | OS1113 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085R0202X | 2004-00278 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | OS11113 | FL | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | 2004-00278 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0202X | OS11113 | FL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 189353 | 01 | MEDCOST | OTHER | 2038722D | 01 | NC | MEDICARE | OTHER | 7547722 | 01 | AETNA | OTHER | Q0027M | 05 | SC | MEDICAID | 805973 | 01 | PARTNERS | OTHER | 5901625 | 05 | NC | MEDICAID | 139NM | 01 | BCBS | OTHER | 3810008229 | 05 | WV | MEDICAID | P00367349 | 01 | RR MEDICARE | OTHER |