Provider Demographics
NPI:1366435398
Name:VERGARA, WILFREDO I (MD)
Entity type:Individual
Prefix:
First Name:WILFREDO
Middle Name:I
Last Name:VERGARA
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:PO BOX 2705
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35804-2705
Mailing Address - Country:US
Mailing Address - Phone:256-801-6047
Mailing Address - Fax:256-801-6218
Practice Address - Street 1:245 GOVERNORS DR SE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-2700
Practice Address - Country:US
Practice Address - Phone:256-265-7981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1402662080P0203X
AL277402080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009914158Medicaid
LA1587052Medicaid
OH2273678Medicaid
TX207477501Medicaid
LA4M321CQ62Medicare PIN
OHVE4153581Medicare ID - Type Unspecified
AR155639001Medicaid