Provider Demographics
NPI:1033119854
Name:VEGA, LUIS R (M D)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:R
Last Name:VEGA
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 530062
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-0062
Mailing Address - Country:US
Mailing Address - Phone:843-695-6071
Mailing Address - Fax:843-569-5881
Practice Address - Street 1:300 MAPLE ST W
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:SC
Practice Address - Zip Code:29924-3238
Practice Address - Country:US
Practice Address - Phone:803-943-3813
Practice Address - Fax:803-943-5971
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23033208M00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00846508OtherRR MEDICARE
SC230333Medicaid
SCGP5367OtherMEDICAID GROUP
SCGP5421OtherGROUP MEDICAID
SC230333Medicaid
SCH775838798Medicare PIN
SCGP5367OtherMEDICAID GROUP