Provider Demographics
NPI:1932893302
Name:VERGARA VILLAREAL, LUIS A (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:A
Last Name:VERGARA VILLAREAL
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 1:1807 SW 153RD PASS
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33185-5722
Mailing Address - Country:US
Mailing Address - Phone:786-260-9845
Mailing Address - Fax:
Practice Address - Street 1:1600 W OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33311-1520
Practice Address - Country:US
Practice Address - Phone:754-200-8248
Practice Address - Fax:954-400-5485
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR22927208D00000X
FLACN1560208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice