1619179058 NPI number — DR. MARK ANTHONY VERGARA-GOMEZ M.D.

Table of content: DR. MARK ANTHONY VERGARA-GOMEZ M.D. (NPI 1619179058)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619179058 NPI number — DR. MARK ANTHONY VERGARA-GOMEZ M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VERGARA-GOMEZ
Provider First Name:
MARK
Provider Middle Name:
ANTHONY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619179058
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PMB 285 PO BOX 1283
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN LORENZO
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00754-1283
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-225-3452
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
AVE. 65TH INFANTERIA KM 8.3 CARR. 3
Provider Second Line Business Practice Location Address:
HOSPITAL UPR, DR. FEDERICO TRILLA
Provider Business Practice Location Address City Name:
CAROLINA
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00984
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-757-1800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/05/2007

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: 207RC0200X , with the licence number:  16704 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: 16704 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RS0012X , with the licence number: 16704 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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