Provider Demographics
NPI:1700292208
Name:VARGHESE, VIJU
Entity type:Individual
Prefix:
First Name:VIJU
Middle Name:
Last Name:VARGHESE
Suffix:
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:SANFORD BROADWAY CLINIC
Mailing Address - Street 2:801 BROADWAY NORTH
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58102-4662
Mailing Address - Country:US
Mailing Address - Phone:765-491-8470
Mailing Address - Fax:
Practice Address - Street 1:801 BROADWAY N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-3641
Practice Address - Country:US
Practice Address - Phone:701-234-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPT14741207R00000X
ND390200000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1700292208OtherHOSPITALIST, INTERNAL MEDICINE