Provider Demographics
NPI:1942315916
Name:VERGARA, EDWARD M (LO)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:M
Last Name:VERGARA
Suffix:
Gender:M
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:656 NEW HAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-2528
Mailing Address - Country:US
Mailing Address - Phone:203-736-2675
Mailing Address - Fax:
Practice Address - Street 1:656 NEW HAVEN AVE
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-2528
Practice Address - Country:US
Practice Address - Phone:203-736-2675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004086949Medicaid
0331140001Medicare ID - Type Unspecified