Provider Demographics
NPI:1083879019
Name:RODERICK V. VERGEL DE DIOS, M.D., P.A.
Entity Type:Organization
Organization Name:RODERICK V. VERGEL DE DIOS, M.D., P.A.
Other - Org Name:VERGEL DE DIOS FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:VILLAROMAN
Authorized Official - Last Name:VERGEL DE DIOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-686-6644
Mailing Address - Street 1:5105 N MCCOLL RD
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-2331
Mailing Address - Country:US
Mailing Address - Phone:956-686-6644
Mailing Address - Fax:956-686-6643
Practice Address - Street 1:5105 N MCCOLL RD
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-2331
Practice Address - Country:US
Practice Address - Phone:956-686-6644
Practice Address - Fax:956-686-6643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-18
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1713207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
080152499OtherRAILROAD MEDICARE
5805616OtherAETNA
TX0021DFOtherBLUE CROSS BLUE SHIELD
116761OtherSUPERIOR HEALTH PLAN
TX126632205OtherMEDICAID EPSDT
A001OtherCHAMPUS
A002OtherTRICARE
TX126632202Medicaid
TX0021DFOtherBLUE CROSS BLUE SHIELD
TX126632205OtherMEDICAID EPSDT
5805616OtherAETNA
00509GMedicare PIN