Provider Demographics
NPI:1184669244
Name:VERGARA, JOCELYN BLANDO (MD)
Entity type:Individual
Prefix:DR
First Name:JOCELYN
Middle Name:BLANDO
Last Name:VERGARA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JOCELYN
Other - Middle Name:VERGARA
Other - Last Name:REALUBIT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10410 RIDGEFIELD PKWY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-3544
Mailing Address - Country:US
Mailing Address - Phone:804-754-3776
Mailing Address - Fax:804-754-0880
Practice Address - Street 1:10410 RIDGEFIELD PKWY
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-3544
Practice Address - Country:US
Practice Address - Phone:804-754-3776
Practice Address - Fax:804-754-0880
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010497942080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101049794OtherLICENSE TO PRACTICE
VA0101049794OtherLICENSE TO PRACTICE