Provider Demographics
NPI:1871677336
Name:VARGHESE, ANNIE (MD)
Entity Type:Individual
Prefix:MRS
First Name:ANNIE
Middle Name:
Last Name:VARGHESE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 WINN WAY SUITE 130
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030
Mailing Address - Country:US
Mailing Address - Phone:404-508-1208
Mailing Address - Fax:404-508-1248
Practice Address - Street 1:465 WINN WAY SUITE 130
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030
Practice Address - Country:US
Practice Address - Phone:404-508-1208
Practice Address - Fax:404-508-1248
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA020614208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00542066HMedicaid
GA00542066HMedicaid