Provider Demographics
NPI:1104988625
Name:VARGAS, VICTOR MANUEL (MD)
Entity type:Individual
Prefix:DR
First Name:VICTOR
Middle Name:MANUEL
Last Name:VARGAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 W COCOA BEACH CSWY
Practice Address - Street 2:
Practice Address - City:COCOA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32931-3585
Practice Address - Country:US
Practice Address - Phone:321-868-5871
Practice Address - Fax:321-868-5852
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2020-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME102275208M00000X, 208M00000X
NC134421390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005981200Medicaid
FLP01410874OtherRR MEDICARE
FLP02171494OtherRRMEDICARE PTAN
FLKQ829OtherMEDICARE PTAN