Provider Demographics
NPI:1487697553
Name:VARGAS, MARCEL MOSES
Entity type:Individual
Prefix:
First Name:MARCEL
Middle Name:MOSES
Last Name:VARGAS
Suffix:
Gender:M
Credentials:
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 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2131 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7407
Practice Address - Country:US
Practice Address - Phone:910-667-7000
Practice Address - Fax:910-815-5698
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-01267208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ0126QMedicaid
NC1487697553Medicaid
NCNCQ290CMedicare PIN
NCNCQ290AMedicare PIN
NCNCQ290DMedicare PIN
NC1487697553Medicaid