Provider Demographics
NPI:1083661938
Name:IGLESIAS VERGARA, ALBERTO RAFAEL (MD)
Entity Type:Individual
Prefix:
First Name:ALBERTO
Middle Name:RAFAEL
Last Name:IGLESIAS VERGARA
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 1:2900 CORPORATE WAY
Mailing Address - Street 2:DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3925
Mailing Address - Country:US
Mailing Address - Phone:954-276-5685
Mailing Address - Fax:954-985-7074
Practice Address - Street 1:1951 SW 172ND AVE
Practice Address - Street 2:SUITE 408
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33029
Practice Address - Country:US
Practice Address - Phone:954-538-5470
Practice Address - Fax:954-538-5477
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98717208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279848400Medicaid
FLAG002YOtherMEDICARE PTAN
MD405361300Medicaid
FLAG002YOtherMEDICARE PTAN
FL279848400Medicaid