Provider Demographics
NPI:1407498371
Name:VARGHESE, SAJAN THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:SAJAN
Middle Name:THOMAS
Last Name:VARGHESE
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 1:1701 SE HILLMOOR DR STE 5
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7552
Mailing Address - Country:US
Mailing Address - Phone:772-335-0060
Mailing Address - Fax:
Practice Address - Street 1:1701 SE HILLMOOR DR STE 5
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7552
Practice Address - Country:US
Practice Address - Phone:772-335-0060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-12
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHSE29940208D00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice