Provider Demographics
NPI:1255009916
Name:VARGAS-DE LEON, IRWIN
Entity Type:Individual
Prefix:
First Name:IRWIN
Middle Name:
Last Name:VARGAS-DE LEON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 W 189TH ST APT 3E
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10040-4224
Mailing Address - Country:US
Mailing Address - Phone:484-219-8664
Mailing Address - Fax:
Practice Address - Street 1:620 W 189TH ST APT 3E
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10040-4224
Practice Address - Country:US
Practice Address - Phone:484-219-8664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1498314211174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist