Provider Demographics
NPI:1619450251
Name:VARGAS, JORGE J
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:J
Last Name:VARGAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9507 LETTERSTONE CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-1972
Mailing Address - Country:US
Mailing Address - Phone:813-385-4860
Mailing Address - Fax:
Practice Address - Street 1:9507 LETTERSTONE CT
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-1972
Practice Address - Country:US
Practice Address - Phone:813-385-4860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-10
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL83-1848914Medicaid