Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 48264 | WI |
N | 207RG0300X | Geriatric Medicine | 48264 | WI |
NPI | 1134131626 |
---|---|
Provider Name | Reny Varghese |
First Address | Milwaukee, WI 53215-2843 |
Second Address | Milwaukee, WI 53202 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/08/2006 |
Last Update Date | 06/12/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
BV8742492 | DEA (01) | WI |