Basic Information
| Provider Information | |||||||||
| NPI: | 1871909523 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VARGAS | ||||||||
| FirstName: | ISAAC | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 WATSON BLVD | ||||||||
| Address2: | ATTN: DECISION SUPPORT/PROVIDER ENROLLMENT | ||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310933431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789224281 | ||||||||
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| Practice Location | |||||||||
| Address1: | 233 N HOUSTON RD STE 140A | ||||||||
| Address2: | |||||||||
| City: | WARNER ROBINS | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4789232843 | ||||||||
| FaxNumber: | 4789756766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2014 | ||||||||
| LastUpdateDate: | 06/12/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | UO3275 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 073867 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 003161121A | 05 | GA | MEDICAID |