Provider Demographics
NPI:1417931353
Name:ATIENZA, VERGEL S (MD)
Entity Type:Individual
Prefix:
First Name:VERGEL
Middle Name:S
Last Name:ATIENZA
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 1:95 OXFORD CIR
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:VA
Mailing Address - Zip Code:24151-2134
Mailing Address - Country:US
Mailing Address - Phone:540-483-7659
Mailing Address - Fax:
Practice Address - Street 1:390 S MAIN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151-1711
Practice Address - Country:US
Practice Address - Phone:540-484-4800
Practice Address - Fax:540-484-4862
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-050995207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005618703Medicaid
VA005621453Medicaid
VA453496OtherANTHEM
VA005618703Medicaid
VA453496OtherANTHEM
VA080088494Medicare PIN
F83162Medicare UPIN