Provider Demographics
NPI:1104361997
Name:VARGAS, JEAN PAUL DENNIS (IDC)
Entity Type:Individual
Prefix:
First Name:JEAN PAUL
Middle Name:DENNIS
Last Name:VARGAS
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 MICHAEL RD APT F
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-2451
Mailing Address - Country:US
Mailing Address - Phone:862-668-6788
Mailing Address - Fax:
Practice Address - Street 1:96 MICHAEL RD APT F
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-2451
Practice Address - Country:US
Practice Address - Phone:862-668-6788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-03
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman