Healthcare Provider Details

I. General information

NPI: 1003849043
Provider Name (Legal Business Name): NILDA VERGARA M.D. A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 02/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2039 FOREST AVE STE 205B
SAN JOSE CA
95128-4815
US

IV. Provider business mailing address

2039 FOREST AVE STE 205B
SAN JOSE CA
95128-4815
US

V. Phone/Fax

Practice location:
  • Phone: 408-295-0211
  • Fax: 408-297-9326
Mailing address:
  • Phone: 408-295-0211
  • Fax: 408-297-9326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA37908
License Number StateCA

VIII. Authorized Official

Name: DR. NILDA VERGARA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 408-295-0211