Provider Demographics
NPI:1003136367
Name:VARGHESE, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:VARGHESE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 REID PARKWAY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374
Mailing Address - Country:US
Mailing Address - Phone:765-935-8802
Mailing Address - Fax:765-983-3219
Practice Address - Street 1:1100 REID PKWY
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1157
Practice Address - Country:US
Practice Address - Phone:765-983-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-09
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV25429207R00000X
MI4301096387207R00000X
IN01077384A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300032913Medicaid