Provider Demographics
NPI:1083606990
Name:VARGO, SUSAN M (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:VARGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 EMBASSY PKWY STE 260
Mailing Address - Street 2:
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-8398
Mailing Address - Country:US
Mailing Address - Phone:330-664-8120
Mailing Address - Fax:330-664-8121
Practice Address - Street 1:3800 EMBASSY PKWY STE 260
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-8398
Practice Address - Country:US
Practice Address - Phone:330-664-8120
Practice Address - Fax:330-664-8121
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35053909208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0659710Medicaid
F47360Medicare UPIN
OH0659710Medicaid