Provider Demographics
NPI:1629193891
Name:VERGHESE, GEORGE K
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:K
Last Name:VERGHESE
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:PO BOX 1409
Mailing Address - Street 2:
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-1409
Mailing Address - Country:US
Mailing Address - Phone:301-475-8091
Mailing Address - Fax:301-745-6712
Practice Address - Street 1:26840 POINT LOOKOUT RD
Practice Address - Street 2:
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650
Practice Address - Country:US
Practice Address - Phone:301-475-8091
Practice Address - Fax:301-475-6712
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0065320207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00688578Medicare PIN
MD061LS432Medicare PIN