Provider Demographics
NPI:1083780761
Name:DE LA VEGA, GUILLERMO ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:ANTONIO
Last Name:DE LA 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:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:484-884-0699
Practice Address - Street 1:1611 POND ROAD
Practice Address - Street 2:SUITE 401
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18104
Practice Address - Country:US
Practice Address - Phone:610-398-7700
Practice Address - Fax:610-398-6917
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD429959207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA108650KZKMedicaid
I71216Medicare UPIN