Provider Demographics
NPI:1043501000
Name:VEGA, MIRNALIS MARTINEZ (DO)
Entity Type:Individual
Prefix:DR
First Name:MIRNALIS
Middle Name:MARTINEZ
Last Name:VEGA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:MIRNA
Other - Middle Name:LIS
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2124 CANDLER RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-5572
Mailing Address - Country:US
Mailing Address - Phone:404-836-0272
Mailing Address - Fax:404-666-0038
Practice Address - Street 1:2124 CANDLER RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-5572
Practice Address - Country:US
Practice Address - Phone:404-836-0272
Practice Address - Fax:404-666-0038
Is Sole Proprietor?:No
Enumeration Date:2011-04-26
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA96939207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine