Provider Demographics
NPI:1033150800
Name:VENGOECHEA, FABIAN A (MD)
Entity Type:Individual
Prefix:
First Name:FABIAN
Middle Name:A
Last Name:VENGOECHEA
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 1:257 W CAYUGA ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19140-2439
Mailing Address - Country:US
Mailing Address - Phone:267-368-6953
Mailing Address - Fax:215-621-6940
Practice Address - Street 1:7600 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2442
Practice Address - Country:US
Practice Address - Phone:215-728-2000
Practice Address - Fax:215-214-4119
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD427681207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PACD4829OtherRAIL ROAD MEDICARE GROUP TPI
PA1007278000OtherMEDICAID TPI GROUP
PA597586OtherMEDICARE GROUP TPI
PA1007278000OtherMEDICAID TPI GROUP