Provider Demographics
NPI:1609857127
Name:DOLOR, WILFREDO VERGARA (MD)
Entity Type:Individual
Prefix:
First Name:WILFREDO
Middle Name:VERGARA
Last Name:DOLOR
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 1:6602 WATERS AVE BLDG A
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-2778
Mailing Address - Country:US
Mailing Address - Phone:912-350-6000
Mailing Address - Fax:912-350-6001
Practice Address - Street 1:6602 WATERS AVE BLDG A
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-2778
Practice Address - Country:US
Practice Address - Phone:912-350-6000
Practice Address - Fax:912-350-6001
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043922207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCG43922Medicaid
GA000788268EMedicaid
GA000788268GMedicaid
GA52598660-005OtherBCBS
GA349752OtherWELLCARE
GAP00328076OtherRR MEDICARE
GA10064383OtherAMERIGROUP
SCG43922Medicaid
GA11SCGBHMedicare PIN