Provider Demographics
NPI:1922196013
Name:VARGHESE, JACOB ALEX MATHEW (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:ALEX MATHEW
Last Name:VARGHESE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JACOB
Other - Middle Name:
Other - Last Name:VARGHESE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-366-2983
Mailing Address - Fax:
Practice Address - Street 1:19200 N KELSEY ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1431
Practice Address - Country:US
Practice Address - Phone:360-794-7994
Practice Address - Fax:360-805-4757
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD419174208000000X
UT57074561205208000000X
WAMD60523725208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT942854057014Medicaid
UT942854058940Medicaid
UT000063583Medicare PIN
WAG8937274Medicare UPIN
UT942854057014Medicaid
UT005738113Medicare ID - Type UnspecifiedINTERMOUNTAIN PEDIATRICS
H61864Medicare UPIN