Provider Demographics
NPI:1902807118
Name:VARGO, BRADLEY (DO)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:VARGO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11255 WOODLAKE DR
Mailing Address - Street 2:
Mailing Address - City:KIRTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44094-9556
Mailing Address - Country:US
Mailing Address - Phone:216-832-9683
Mailing Address - Fax:440-256-3147
Practice Address - Street 1:11255 WOODLAKE DR
Practice Address - Street 2:
Practice Address - City:KIRTLAND
Practice Address - State:OH
Practice Address - Zip Code:44094-9556
Practice Address - Country:US
Practice Address - Phone:216-832-9683
Practice Address - Fax:440-256-3147
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004864207LC0200X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000221087OtherUNISON
OH415050OtherWELLCARE MEDICAID
OH0583328OtherBCMH
OH751022OtherBUCKEYE MEDICAID
5693771OtherAETNA
OH000000521139OtherANTHEM
OH0825816Medicaid
5693771OtherAETNA
OH000000221087OtherUNISON
OH415050OtherWELLCARE MEDICAID