=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598154890
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES VARGHESE M D
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2015
-----------------------------------------------------
Last Update Date | 01/10/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 782 SW SISTERS WELCOME RD
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32025-0442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-755-4518
-----------------------------------------------------
Fax | 386-758-4500
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 782 SW SISTERS WELCOME RD
-----------------------------------------------------
City | LAKE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32025-0442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-755-4518
-----------------------------------------------------
Fax | 386-758-4500
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. SHERLY J VARGHESE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 386-209-5518
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | ME67182
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------