Provider Demographics
NPI:1164788758
Name:VERGARA, MICHAEL MONGCOPA (PT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:MONGCOPA
Last Name:VERGARA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 LAURELWOOD RD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-4206
Mailing Address - Country:US
Mailing Address - Phone:860-326-5729
Mailing Address - Fax:
Practice Address - Street 1:1145 POQUONNOCK RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4620
Practice Address - Country:US
Practice Address - Phone:860-449-0289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-09
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0007361225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist