Provider Demographics
NPI:1265967806
Name:VARGHESE, RENNY (MD)
Entity type:Individual
Prefix:
First Name:RENNY
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 1:2660 GULF FWY S STE 3
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-6820
Mailing Address - Country:US
Mailing Address - Phone:832-505-2200
Mailing Address - Fax:281-337-0719
Practice Address - Street 1:2660 GULF FWY S STE 3
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-6820
Practice Address - Country:US
Practice Address - Phone:832-505-2200
Practice Address - Fax:281-337-0719
Is Sole Proprietor?:No
Enumeration Date:2017-04-20
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10060980390200000X
TXR9311207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program