Provider Demographics
NPI:1538894829
Name:VERGARA, MIGUEL IV
Entity type:Individual
Prefix:MR
First Name:MIGUEL
Middle Name:
Last Name:VERGARA
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3216 TITANIC AVE
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79904-3023
Mailing Address - Country:US
Mailing Address - Phone:915-238-6824
Mailing Address - Fax:
Practice Address - Street 1:18511 HIGHLANDER MEDICS ST
Practice Address - Street 2:
Practice Address - City:FORT BLISS
Practice Address - State:TX
Practice Address - Zip Code:79906-5327
Practice Address - Country:US
Practice Address - Phone:915-742-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-20
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX770304171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No171000000XOther Service ProvidersMilitary Health Care Provider