1649248758 NPI number — DR. FREDICKSON MANUEL VARGAS MD

Table of content: DR. FREDICKSON MANUEL VARGAS MD (NPI 1649248758)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649248758 NPI number — DR. FREDICKSON MANUEL VARGAS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VARGAS
Provider First Name:
FREDICKSON
Provider Middle Name:
MANUEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VARGAS
Provider Other First Name:
FREDICKSON
Provider Other Middle Name:
MANUEL
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1649248758
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
HC 3 BOX 25708
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN GERMAN
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00683-9339
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-892-0585
Provider Business Mailing Address Fax Number:
787-892-0588

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
SAN GERMAN MEDICAL PLAZA CARR #2 KM 174
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN GERMAN
Provider Business Practice Location Address State Name:
PR
Provider Business Practice Location Address Postal Code:
00683
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
787-892-0585
Provider Business Practice Location Address Fax Number:
787-892-0588
Provider Enumeration Date:
03/14/2006

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: 207R00000X , with the licence number:  13607 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 13607 . This is a "STATE LICENCE" identifier , issued by the state of ( PR ) . This identifiers is of the category "OTHER".