Provider Demographics
NPI:1710185442
Name:VERGIN, JACOB B (OD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:B
Last Name:VERGIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13151 39TH AVE N
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-7144
Mailing Address - Country:US
Mailing Address - Phone:773-297-5096
Mailing Address - Fax:
Practice Address - Street 1:331 E PRAIRIE VIEW RD
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-3463
Practice Address - Country:US
Practice Address - Phone:715-726-9077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3083-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38642900Medicaid
WI000247999Medicare PIN
WI6046420001Medicare NSC
WI38642900Medicaid
WI6046420002Medicare NSC