Provider Demographics
NPI:1811910532
Name:VARGO, JEFFREY PAUL (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:PAUL
Last Name:VARGO
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 1:11995 SINGLETREE LN
Mailing Address - Street 2:SUITE 500
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-5347
Mailing Address - Country:US
Mailing Address - Phone:952-595-1301
Mailing Address - Fax:612-294-4903
Practice Address - Street 1:209 CALLE POTRANCA
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4552
Practice Address - Country:US
Practice Address - Phone:952-595-1100
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0476522085R0202X
FLME1046492085R0202X
CODR-482662085R0202X
PAMD4285432085R0202X
CAA1090672085R0202X
LAMD2031832085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1016606800001Medicaid
PA101660680Medicaid
PA102613FUDMedicare PIN
PAP00345298Medicare PIN
OHVA4194992Medicare PIN
PA1555738Medicare PIN