Provider Demographics
NPI:1487638268
Name:VERGARA, MANUEL S (MD)
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:S
Last Name:VERGARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3120 PRINCETON PIKE FL 2
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648-2325
Mailing Address - Country:US
Mailing Address - Phone:609-896-1701
Mailing Address - Fax:609-896-3735
Practice Address - Street 1:3120 PRINCETON PIKE FL 2
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-2325
Practice Address - Country:US
Practice Address - Phone:609-896-1701
Practice Address - Fax:609-896-3735
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-05
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA067940002084N0400X, 2084E0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084E0001XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyEpilepsy
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG68143Medicare UPIN
NJ742422Medicare ID - Type Unspecified