Healthcare Provider Details

I. General information

NPI: 1366435398
Provider Name (Legal Business Name): WILFREDO I VERGARA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 GOVERNORS DR SE
HUNTSVILLE AL
35801-2700
US

IV. Provider business mailing address

PO BOX 2705
HUNTSVILLE AL
35804-2705
US

V. Phone/Fax

Practice location:
  • Phone: 256-265-7981
  • Fax:
Mailing address:
  • Phone: 256-801-6047
  • Fax: 256-801-6218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number01051701A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number27740
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberME140266
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: