Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080A0000X | Adolescent Medicine | 0101049794 | VA |
NPI | 1184669244 |
---|---|
Provider Name | Dr. Jocelyn Blando Vergara |
First Address | Richmond, VA 23233-3544 |
Second Address | Richmond, VA 23233-3544 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/06/2006 |
Last Update Date | 18/03/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0101049794 | LICENSE TO PRACTICE (01) | VA |
BR3682994 | DEA (01) |