Provider Demographics
NPI:1114979671
Name:DE LA VEGA, DAGOBERTO (MD)
Entity Type:Individual
Prefix:
First Name:DAGOBERTO
Middle Name:
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 1:3200 SW 128TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33175-2504
Mailing Address - Country:US
Mailing Address - Phone:305-298-9100
Mailing Address - Fax:305-274-0692
Practice Address - Street 1:3200 SW 128TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33175-2504
Practice Address - Country:US
Practice Address - Phone:305-298-9100
Practice Address - Fax:305-274-0692
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-16
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67856207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL377494501Medicaid
FL26980Medicare ID - Type UnspecifiedPROVIDER #