Provider Demographics
NPI:1922062827
Name:VARGHESE, REGI (MD)
Entity Type:Individual
Prefix:DR
First Name:REGI
Middle Name:
Last Name:VARGHESE
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:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-272-5395
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:100 MALLARD CREEK RD STE 320
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-5136
Practice Address - Country:US
Practice Address - Phone:502-855-6125
Practice Address - Fax:502-394-1972
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046412A207R00000X
KY33222207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00476429OtherRAILROAD MEDICARE PTAN
KY64332224Medicaid
KY110150805OtherRAILROAD MEDICARE
KY00546226Medicare Oscar/Certification
KY64332224Medicaid
KYG60924Medicare UPIN
KY0361914Medicare PIN