Healthcare Provider Details

I. General information

NPI: 1962098749
Provider Name (Legal Business Name): RAUL JAVIER VARGAS RIVERA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 E CENTRAL AVE
WINTER HAVEN FL
33880-6312
US

IV. Provider business mailing address

PO BOX 532
LAKE ALFRED FL
33850-0532
US

V. Phone/Fax

Practice location:
  • Phone: 407-315-3637
  • Fax: 407-358-3440
Mailing address:
  • Phone: 407-315-3637
  • Fax: 407-358-3440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMED-PHYS-REG-0002152
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberTPME1150
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberTPPA107
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN1361
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: