Provider Demographics
NPI:1063464527
Name:D DE LA VEGA MD P A
Entity Type:Organization
Organization Name:D DE LA VEGA MD P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAGOBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-298-9100
Mailing Address - Street 1:11093 NW 138TH ST UNIT 112
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33018-1190
Mailing Address - Country:US
Mailing Address - Phone:305-552-0303
Mailing Address - Fax:305-554-0709
Practice Address - Street 1:11093 NW 138TH ST UNIT 112
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33018-1190
Practice Address - Country:US
Practice Address - Phone:305-552-0303
Practice Address - Fax:305-554-0709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67856207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377494501Medicaid
FL26980OtherBCBS PROVIDER#
FLK7294Medicare ID - Type UnspecifiedGROUP PROVIDER #
FL26980OtherBCBS PROVIDER#
FL26980Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER #