Provider Demographics
NPI:1053380584
Name:VASSILENKO, MIKHAIL (MD)
Entity type:Individual
Prefix:
First Name:MIKHAIL
Middle Name:
Last Name:VASSILENKO
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 1:1065 NE 125TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-5833
Mailing Address - Country:US
Mailing Address - Phone:786-221-0908
Mailing Address - Fax:305-891-4228
Practice Address - Street 1:10301 HAGEN RANCH RD STE B200
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33437-3723
Practice Address - Country:US
Practice Address - Phone:561-752-9490
Practice Address - Fax:561-752-9491
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD062001L2084P0800X
FLME1560212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114812600Medicaid
PA002821Medicare UPIN
PAG60797Medicare UPIN