Basic Information
| Provider Information | |||||||||
| NPI: | 1679736219 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VARGAS | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | BIBIANA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 19676 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627949676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003312229 | ||||||||
| FaxNumber: | 2177576844 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 N 9TH ST | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 627025303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003312229 | ||||||||
| FaxNumber: | 2177576844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2008 | ||||||||
| LastUpdateDate: | 11/19/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 036116016 | IL | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080N0001X | 036-116016 | IL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036116016 | 05 | IL | MEDICAID |