Healthcare Provider Details

I. General information

NPI: 1407883051
Provider Name (Legal Business Name): ANNIE VERGHESE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 07/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23415 THREE NOTCH RD SUITE 2052
CALIFORNIA MD
20619-4017
US

IV. Provider business mailing address

41040 PAW PAW HOLLOW LN
LEONARDTOWN MD
20650-2160
US

V. Phone/Fax

Practice location:
  • Phone: 240-237-8268
  • Fax: 240-237-8446
Mailing address:
  • Phone: 301-475-5704
  • Fax: 301-475-9483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberD0015709
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: