Provider Demographics
NPI:1558367581
Name:VAGOVIC, RICHARD J (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:VAGOVIC
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 1:311 N CLYDE MORRIS BLVD STE 420
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2757
Mailing Address - Country:US
Mailing Address - Phone:386-274-1005
Mailing Address - Fax:386-274-5779
Practice Address - Street 1:311 NORTH CLYDE MORRIS BLVD
Practice Address - Street 2:STE 420
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1493
Practice Address - Country:US
Practice Address - Phone:386-274-1005
Practice Address - Fax:386-274-5779
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME55416207V00000X, 207VG0400X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064259200Medicaid
FLE94358Medicare UPIN
FL064259200Medicaid