Provider Demographics
NPI:1124275979
Name:VARGHESE, MINI (MD)
Entity type:Individual
Prefix:DR
First Name:MINI
Middle Name:
Last Name:VARGHESE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1270 STUMP RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-4530
Mailing Address - Country:US
Mailing Address - Phone:215-364-0262
Mailing Address - Fax:
Practice Address - Street 1:5501 OLD YORK RD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3018
Practice Address - Country:US
Practice Address - Phone:215-456-6006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-23
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4517392084P0800X
390200000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171M00000XOther Service ProvidersCase Manager/Care Coordinator