Healthcare Provider Details

I. General information

NPI: 1932259389
Provider Name (Legal Business Name): RAFAEL VERGARA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 11/14/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17762 BEACH BLVD SUITE 220
HUNTINGTON BEACH CA
92647-6860
US

IV. Provider business mailing address

17762 BEACH BLVD SUITE 220
HUNTINGTON BEACH CA
92647-6860
US

V. Phone/Fax

Practice location:
  • Phone: 714-848-0080
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA52192
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: