Provider Demographics
NPI:1962098749
Name:VARGAS RIVERA, RAUL JAVIER (MD)
Entity type:Individual
Prefix:DR
First Name:RAUL
Middle Name:JAVIER
Last Name:VARGAS RIVERA
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 532
Mailing Address - Street 2:
Mailing Address - City:LAKE ALFRED
Mailing Address - State:FL
Mailing Address - Zip Code:33850-0532
Mailing Address - Country:US
Mailing Address - Phone:407-315-3637
Mailing Address - Fax:407-358-3440
Practice Address - Street 1:217 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-6312
Practice Address - Country:US
Practice Address - Phone:407-315-3637
Practice Address - Fax:407-358-3440
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PHYS-REG-0002152208D00000X
FLTPME1150208D00000X
FLTPPA107363AM0700X
FLACN1361208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty