Provider Demographics
NPI:1093853897
Name:VEGA, CORALYS MERCEDES (MD)
Entity Type:Individual
Prefix:
First Name:CORALYS
Middle Name:MERCEDES
Last Name:VEGA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4053 75TH ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1011
Mailing Address - Country:US
Mailing Address - Phone:718-426-6270
Mailing Address - Fax:718-504-5422
Practice Address - Street 1:4053 75TH ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1011
Practice Address - Country:US
Practice Address - Phone:718-426-6270
Practice Address - Fax:718-504-5422
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY220555208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02167191Medicaid