Provider Demographics
NPI:1649248758
Name:VARGAS, FREDICKSON MANUEL (MD)
Entity type:Individual
Prefix:DR
First Name:FREDICKSON
Middle Name:MANUEL
Last Name:VARGAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:FREDICKSON
Other - Middle Name:MANUEL
Other - Last Name:VARGAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:HC 3 BOX 25708
Mailing Address - Street 2:
Mailing Address - City:SAN GERMAN
Mailing Address - State:PR
Mailing Address - Zip Code:00683-9339
Mailing Address - Country:US
Mailing Address - Phone:787-892-0585
Mailing Address - Fax:787-892-0588
Practice Address - Street 1:SAN GERMAN MEDICAL PLAZA CARR #2 KM 174
Practice Address - Street 2:
Practice Address - City:SAN GERMAN
Practice Address - State:PR
Practice Address - Zip Code:00683
Practice Address - Country:US
Practice Address - Phone:787-892-0585
Practice Address - Fax:787-892-0588
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR13607207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR13607OtherSTATE LICENCE
PRH63409Medicare UPIN
PR20970Medicare ID - Type UnspecifiedPROVIDER NUMBER