Provider Demographics
NPI:1407921604
Name:VARGES, VANTUIL L (MD)
Entity Type:Individual
Prefix:DR
First Name:VANTUIL
Middle Name:L
Last Name:VARGES
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 1:1778 UNION CARBIDE RD
Mailing Address - Street 2:
Mailing Address - City:WOODBINE
Mailing Address - State:GA
Mailing Address - Zip Code:31569-4336
Mailing Address - Country:US
Mailing Address - Phone:912-673-6706
Mailing Address - Fax:
Practice Address - Street 1:96B LAKESHORE DR
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-3851
Practice Address - Country:US
Practice Address - Phone:912-882-2167
Practice Address - Fax:912-882-2169
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA39689174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP6548Medicare ID - Type Unspecified
GAC59261Medicare UPIN