Provider Demographics
NPI:1730170143
Name:MASSULLO, VINCENT (MD)
Entity type:Individual
Prefix:
First Name:VINCENT
Middle Name:
Last Name:MASSULLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 TREAT BLVD # 300
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-2168
Mailing Address - Country:US
Mailing Address - Phone:925-952-2828
Mailing Address - Fax:
Practice Address - Street 1:2540 EAST ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-1906
Practice Address - Country:US
Practice Address - Phone:209-342-2300
Practice Address - Fax:209-524-4240
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG507232085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G507230Medicaid
CA00G507231OtherBLUE SHIELD
CA00G507230Medicaid
CA00G507231OtherBLUE SHIELD