Provider Demographics
NPI:1609888247
Name:VERGNE, RAYMOND (MD)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:
Last Name:VERGNE
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 1:3301 WOODBURN RD STE 301
Mailing Address - Street 2:
Mailing Address - City:ANNANDALE
Mailing Address - State:VA
Mailing Address - Zip Code:22003-1294
Mailing Address - Country:US
Mailing Address - Phone:703-204-9301
Mailing Address - Fax:
Practice Address - Street 1:3301 WOODBURN RD STE 301
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:VA
Practice Address - Zip Code:22003-1294
Practice Address - Country:US
Practice Address - Phone:703-204-9301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101045676174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6052321Medicaid
VA111587Medicare ID - Type Unspecified
VAB34860Medicare UPIN