Provider Demographics
NPI:1699752642
Name:VERGARA, JESUS ROBERTO (MD)
Entity type:Individual
Prefix:DR
First Name:JESUS
Middle Name:ROBERTO
Last Name:VERGARA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:532 LAFAYETTE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-4411
Mailing Address - Country:US
Mailing Address - Phone:973-940-0423
Mailing Address - Fax:973-940-0399
Practice Address - Street 1:111 E CATHERINE ST
Practice Address - Street 2:SUITE 110
Practice Address - City:MILFORD
Practice Address - State:PA
Practice Address - Zip Code:18337-1347
Practice Address - Country:US
Practice Address - Phone:570-296-4600
Practice Address - Fax:570-409-1965
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038493E207R00000X
NJ25MA04749800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6749305Medicaid
NJ010050488OtherNJ RAILROAD MEDICARE
PA010051532OtherPA RAILROAD MEDICARE
NJ010050488OtherNJ RAILROAD MEDICARE
NJ612483Medicare PIN
PA444418MVBMedicare PIN