Provider Demographics
NPI:1538120290
Name:VERGARA, GRACIE D (MD)
Entity Type:Individual
Prefix:DR
First Name:GRACIE
Middle Name:D
Last Name:VERGARA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GRACIE
Other - Middle Name:D
Other - Last Name:BERNARDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1005 COMMERCIAL LN
Mailing Address - Street 2:SUITE 220
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8149
Mailing Address - Country:US
Mailing Address - Phone:757-668-2600
Mailing Address - Fax:757-668-2620
Practice Address - Street 1:1005 COMMERCIAL LN
Practice Address - Street 2:SUITE 220
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8149
Practice Address - Country:US
Practice Address - Phone:757-668-2600
Practice Address - Fax:757-668-2620
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101056502208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891154TMedicaid
NCG59662Medicare UPIN