Provider Demographics
NPI:1396184289
Name:MEDINA VARGAS, ASERET D (MD)
Entity Type:Individual
Prefix:DR
First Name:ASERET
Middle Name:D
Last Name:MEDINA VARGAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ASERET
Other - Middle Name:DE LOS ANGELES
Other - Last Name:MEDINA VARGAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2900 CORPORATE WAY
Mailing Address - Street 2:DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3925
Mailing Address - Country:US
Mailing Address - Phone:954-276-5685
Mailing Address - Fax:954-985-7074
Practice Address - Street 1:17786 SW 2ND ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-3923
Practice Address - Country:US
Practice Address - Phone:542-765-5522
Practice Address - Fax:954-436-6875
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-24
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME116631207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL113197000Medicaid