Provider Demographics
NPI:1073545984
Name:VEGA, JUAN ANGEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:ANGEL
Last Name:VEGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 RED MILLS RD
Mailing Address - Street 2:
Mailing Address - City:WALLKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12589-3220
Mailing Address - Country:US
Mailing Address - Phone:845-744-9105
Mailing Address - Fax:845-744-9107
Practice Address - Street 1:800 RED MILLS RD
Practice Address - Street 2:
Practice Address - City:WALLKILL
Practice Address - State:NY
Practice Address - Zip Code:12589-3220
Practice Address - Country:US
Practice Address - Phone:845-744-9105
Practice Address - Fax:845-744-9107
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9837208000000X
NY238612208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110715302Medicaid
TX110715302Medicaid