Provider Demographics
NPI:1790740306
Name:WARGO, JENNIFER T (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:T
Last Name:WARGO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:TUMULTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8629 SUDLEY RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4590
Mailing Address - Country:US
Mailing Address - Phone:703-361-3030
Mailing Address - Fax:703-361-2687
Practice Address - Street 1:8629 SUDLEY RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4590
Practice Address - Country:US
Practice Address - Phone:703-361-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012306482085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6688-0021OtherCAREFIRST
VA7237529Medicaid
VA7237511Medicaid
VA7237464Medicaid
VA7237456Medicaid
VA7247575Medicaid
VA7237464Medicaid
VA7247575Medicaid