Provider Demographics
NPI:1083028898
Name:FREDERICK J DE LA VEGA, MD
Entity Type:Organization
Organization Name:FREDERICK J DE LA VEGA, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:DE LA VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-677-1755
Mailing Address - Street 1:23052 ALICIA PKWY
Mailing Address - Street 2:# 619
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-1643
Mailing Address - Country:US
Mailing Address - Phone:714-808-9797
Mailing Address - Fax:714-808-9393
Practice Address - Street 1:9834 GENESEE AVE
Practice Address - Street 2:411
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1223
Practice Address - Country:US
Practice Address - Phone:858-677-1755
Practice Address - Fax:858-677-1771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81923174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty