Healthcare Provider Details

I. General information

NPI: 1922196013
Provider Name (Legal Business Name): JACOB ALEX MATHEW VARGHESE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JACOB VARGHESE M.D.

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19200 N KELSEY ST
MONROE WA
98272-1431
US

IV. Provider business mailing address

PO BOX 3360
PORTLAND OR
97208-3360
US

V. Phone/Fax

Practice location:
  • Phone: 360-794-7994
  • Fax: 360-805-4757
Mailing address:
  • Phone: 866-366-2983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD419174
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number57074561205
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD60523725
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: