Provider Demographics
NPI:1225177488
Name:WARGOVICH, TERESA DOLORES (MD)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:DOLORES
Last Name:WARGOVICH
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 1:5200 N CROATAN HWY
Mailing Address - Street 2:
Mailing Address - City:KITTY HAWK
Mailing Address - State:NC
Mailing Address - Zip Code:27949-3990
Mailing Address - Country:US
Mailing Address - Phone:252-261-4187
Mailing Address - Fax:252-261-5182
Practice Address - Street 1:5200 N CROATAN HWY
Practice Address - Street 2:BEACH MEDICAL CARE, LTD.
Practice Address - City:KITTY HAWK
Practice Address - State:NC
Practice Address - Zip Code:27949
Practice Address - Country:US
Practice Address - Phone:252-261-4187
Practice Address - Fax:252-261-5182
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2014-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-01306207Q00000X
MI4301052029207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4318839OtherAETNA
MI1407385OtherCIGNA
MI06356521001Medicare ID - Type Unspecified
MI0635652OtherBLUE CROSS BLUE SHIELD
MI103805OtherCARE CHOICES
MIC2482OtherMCARE
MIF14644Medicare UPIN