Provider Demographics
NPI:1679760383
Name:BORNACELLI VERGARA, RICARDO (MD)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:
Last Name:BORNACELLI VERGARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RICARDO
Other - Middle Name:
Other - Last Name:BORNACELLI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:12511 WORLD PLAZA LN
Mailing Address - Street 2:BUILDING 50
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-3991
Mailing Address - Country:US
Mailing Address - Phone:239-939-2622
Mailing Address - Fax:
Practice Address - Street 1:12511 WORLD PLAZA LN
Practice Address - Street 2:BUILDING 50
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-3991
Practice Address - Country:US
Practice Address - Phone:239-939-2622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN8248390200000X
FLME100663207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program