Provider Demographics
NPI:1083898498
Name:LUCILLE VEGA MD, INC.
Entity Type:Organization
Organization Name:LUCILLE VEGA MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LUCILLE
Authorized Official - Middle Name:C
Authorized Official - Last Name:VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-383-7830
Mailing Address - Street 1:962 WARWICK AVE
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02888-3650
Mailing Address - Country:US
Mailing Address - Phone:401-383-7830
Mailing Address - Fax:401-270-1165
Practice Address - Street 1:962 WARWICK AVE
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02888-3650
Practice Address - Country:US
Practice Address - Phone:401-383-7830
Practice Address - Fax:401-270-1165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD10293207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI089021703Medicare PIN