1386682649 NPI number — ANDREA VARGAS O'NEAL MPT

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386682649 NPI number — ANDREA VARGAS O'NEAL MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
O'NEAL
Provider First Name:
ANDREA
Provider Middle Name:
VARGAS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VARGAS
Provider Other First Name:
ANDREA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MPT
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1386682649
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4261 FLIPPEN TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORCROSS
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30092-3927
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-931-7248
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1930 BOBBY JONES DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNS CREEK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30097-2402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-931-7248
Provider Business Practice Location Address Fax Number:
404-920-2154
Provider Enumeration Date:
06/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT26941 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: PT008107 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 220541280A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200801 . This is a "BCBS GA" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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