Provider Demographics
NPI:1689215204
Name:VERGES, JACINTO III
Entity Type:Individual
Prefix:
First Name:JACINTO
Middle Name:
Last Name:VERGES
Suffix:III
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 1:2117 BLUEBIRD ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114-1502
Mailing Address - Country:US
Mailing Address - Phone:619-549-3370
Mailing Address - Fax:
Practice Address - Street 1:2117 BLUEBIRD ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92114-1502
Practice Address - Country:US
Practice Address - Phone:619-549-3370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X
CA171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor