Provider Demographics
NPI:1720510647
Name:VARGOVICH, MARTHA LYNN (MD)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:LYNN
Last Name:VARGOVICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:727 ROYAL AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-5704
Mailing Address - Country:US
Mailing Address - Phone:248-497-0633
Mailing Address - Fax:
Practice Address - Street 1:6777 W MAPLE RD
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3013
Practice Address - Country:US
Practice Address - Phone:800-436-7936
Practice Address - Fax:248-661-6447
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301501584207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine