Provider Demographics
NPI:1548268386
Name:VASSAR, BURNELL (MD)
Entity type:Individual
Prefix:DR
First Name:BURNELL
Middle Name:
Last Name:VASSAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:PORTOLA
Mailing Address - State:CA
Mailing Address - Zip Code:96122-0640
Mailing Address - Country:US
Mailing Address - Phone:530-394-7777
Mailing Address - Fax:
Practice Address - Street 1:2090 NEVADA CITY HWY
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-7702
Practice Address - Country:US
Practice Address - Phone:530-274-5020
Practice Address - Fax:530-274-0769
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62926207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG58004Medicare UPIN