Provider Demographics
NPI:1063553352
Name:MARY VARGHESE MD, A PROFESSIONAL MEDICAL
Entity type:Organization
Organization Name:MARY VARGHESE MD, A PROFESSIONAL MEDICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:VARGHESE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-736-6841
Mailing Address - Street 1:665 S KNICKERBOCKER DR
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-1033
Mailing Address - Country:US
Mailing Address - Phone:408-736-6841
Mailing Address - Fax:408-736-7329
Practice Address - Street 1:665 S KNICKERBOCKER DR
Practice Address - Street 2:SUITE 5
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-1033
Practice Address - Country:US
Practice Address - Phone:408-736-6841
Practice Address - Fax:408-736-7329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52872207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty