Provider Demographics
NPI:1780631515
Name:VERGARA, GEORGE L (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:L
Last Name:VERGARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4685 PONCE DE LEON BLVD
Mailing Address - Street 2:
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33146-2132
Mailing Address - Country:US
Mailing Address - Phone:305-661-2534
Mailing Address - Fax:305-667-7451
Practice Address - Street 1:4685 PONCE DE LEON BLVD
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33146-2132
Practice Address - Country:US
Practice Address - Phone:305-661-2534
Practice Address - Fax:305-667-7451
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 16592207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL056178900Medicaid
FLD59512Medicare UPIN
FL056178900Medicaid