Provider Demographics
NPI:1437413366
Name:VARGHESE, JASON (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
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 1:221 REGENCY PKWY
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-5379
Mailing Address - Country:US
Mailing Address - Phone:817-477-5884
Mailing Address - Fax:817-453-8091
Practice Address - Street 1:221 REGENCY PKWY
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063
Practice Address - Country:US
Practice Address - Phone:817-477-5884
Practice Address - Fax:817-453-8091
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA073512207Q00000X
GA005656207Q00000X
TXR5052207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1111555OtherWELLCARE
GALOCATION: GRMCOtherPEACH STATE HEALTH PLAN
GA30216793OtherSELECT HEALTH
GA003162456AMedicaid
GA03163152OtherAMERIGROUP
SCGA1817Medicaid
GA10000277923OtherBCBS
GA2021088904Medicare PIN