Provider Demographics
NPI:1427015726
Name:VARGAS, TEODORO C (MD)
Entity Type:Individual
Prefix:
First Name:TEODORO
Middle Name:C
Last Name:VARGAS
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 1:319 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PACIFIC
Mailing Address - State:MO
Mailing Address - Zip Code:63069-1505
Mailing Address - Country:US
Mailing Address - Phone:636-271-3500
Mailing Address - Fax:636-271-3508
Practice Address - Street 1:319 N 1ST ST
Practice Address - Street 2:
Practice Address - City:PACIFIC
Practice Address - State:MO
Practice Address - Zip Code:63069-1505
Practice Address - Country:US
Practice Address - Phone:636-271-3500
Practice Address - Fax:636-271-3508
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO34914207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO18297OtherBLUE CROSS/SHIELD
MO200864908Medicaid
MO5523OtherGROUP HEALTH PLAN
MO2052OtherHEALTHCARE USA
MO101254OtherHEALTHLINK
MO100922001OtherUNITED HEALTH CARE
MOK92006OtherEXCLUSIVE CHOICE
MO431173202OtherTIN
MOK92006OtherEXCLUSIVE CHOICE
MO431173202OtherTIN