Provider Demographics
NPI:1093783862
Name:VEGA, SUSAN (DO)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:VEGA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:COUNTRY CLUB
Mailing Address - State:MO
Mailing Address - Zip Code:64505-1014
Mailing Address - Country:US
Mailing Address - Phone:816-232-0743
Mailing Address - Fax:816-364-4151
Practice Address - Street 1:8 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:COUNTRY CLUB
Practice Address - State:MO
Practice Address - Zip Code:64505-1014
Practice Address - Country:US
Practice Address - Phone:816-232-0743
Practice Address - Fax:816-364-4151
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3P07207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO18059179OtherBLUE CROSS BLUE SHIELD
MO243615069Medicaid
MOP00415188OtherRAILROAD MEDICARE
MOP00415188OtherRAILROAD MEDICARE
MO243615069Medicaid