Provider Demographics
NPI:1255306635
Name:VERGARA, ISAAC SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:SAMUEL
Last Name:VERGARA
Suffix:
Gender:M
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:PO BOX 3979
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34230-3979
Mailing Address - Country:US
Mailing Address - Phone:352-482-0308
Mailing Address - Fax:352-482-0311
Practice Address - Street 1:60 SW 17TH ST
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-8142
Practice Address - Country:US
Practice Address - Phone:352-482-0308
Practice Address - Fax:524-820-3113
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87592207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL71246SOtherMEDICARE PTAN
FL7126TOtherMEDICARE PTAN