Healthcare Provider Details

I. General information

NPI: 1811438245
Provider Name (Legal Business Name): JONATHON WALTER VARGO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2017
Last Update Date: 05/02/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 TENEYCK ST
JACKSON MI
49201-2461
US

IV. Provider business mailing address

1 FORD PL STE 3A
DETROIT MI
48202-3450
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-8940
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number4301509047
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: