Provider Demographics
NPI:1285743146
Name:VARGAS, HERNAN I (MD)
Entity type:Individual
Prefix:
First Name:HERNAN
Middle Name:I
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 1:3650 JOSEPH SIEWICK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-1712
Mailing Address - Country:US
Mailing Address - Phone:703-280-5390
Mailing Address - Fax:703-620-0952
Practice Address - Street 1:3650 JOSEPH SIEWICK DR STE 200
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1712
Practice Address - Country:US
Practice Address - Phone:703-280-5390
Practice Address - Fax:703-620-0952
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101247298208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1285743146Medicaid
CA00A488230Medicaid
155102ZAHOtherMEDICARE
CA00A488230Medicaid
CAWA48823CMedicare ID - Type UnspecifiedPPIN
CAWA48823BMedicare ID - Type UnspecifiedPPIN