Provider Demographics
NPI:1164472114
Name:VEGA ORTIZ, CARMEN T
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:T
Last Name:VEGA ORTIZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:COND SANTA ANA
Mailing Address - Street 2:AVE LUIS VIGOREAUX APTO 8E
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00966-2506
Mailing Address - Country:US
Mailing Address - Phone:787-236-3693
Mailing Address - Fax:
Practice Address - Street 1:COND SANTA ANA
Practice Address - Street 2:AVE LUIS VIGOREAUX APTO 8E
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00966-2506
Practice Address - Country:US
Practice Address - Phone:787-236-3693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8925207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0088507Medicare ID - Type Unspecified
PRG00368Medicare UPIN