Provider Demographics
NPI:1407883051
Name:VERGHESE, ANNIE (MD)
Entity Type:Individual
Prefix:DR
First Name:ANNIE
Middle Name:
Last Name:VERGHESE
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 1:41040 PAW PAW HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-2160
Mailing Address - Country:US
Mailing Address - Phone:301-475-5704
Mailing Address - Fax:301-475-9483
Practice Address - Street 1:23415 THREE NOTCH RD
Practice Address - Street 2:SUITE 2052
Practice Address - City:CALIFORNIA
Practice Address - State:MD
Practice Address - Zip Code:20619-4017
Practice Address - Country:US
Practice Address - Phone:240-237-8268
Practice Address - Fax:240-237-8446
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0015709207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD411781600Medicaid
MD061L607AMedicare PIN
070006978Medicare PIN
MD411781600Medicaid