Provider Demographics
NPI:1164502845
Name:DE LA VEGA, ARNALDO (MD)
Entity Type:Individual
Prefix:
First Name:ARNALDO
Middle Name:
Last Name:DE LA VEGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ARNALDO
Other - Middle Name:LUIS
Other - Last Name:DE LA VEGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12781 WORLD PLAZA LN STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-4078
Mailing Address - Country:US
Mailing Address - Phone:239-277-5877
Mailing Address - Fax:239-277-1354
Practice Address - Street 1:12781 WORLD PLAZA LN STE 1
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-4078
Practice Address - Country:US
Practice Address - Phone:239-277-5877
Practice Address - Fax:239-277-1354
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101292208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000107700Medicaid