Provider Demographics
NPI:1679846422
Name:VARGAS, EDGAR
Entity Type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:
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 1:10720 NORTHERN BLVD
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-1236
Mailing Address - Country:US
Mailing Address - Phone:718-651-0096
Mailing Address - Fax:718-457-3932
Practice Address - Street 1:10720 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-1236
Practice Address - Country:US
Practice Address - Phone:718-651-0096
Practice Address - Fax:718-457-3932
Is Sole Proprietor?:No
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18547101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)