Provider Demographics
NPI:1275512873
Name:VEGA, IVONNE JEANNETTE (BS)
Entity Type:Individual
Prefix:
First Name:IVONNE
Middle Name:JEANNETTE
Last Name:VEGA
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5717 NW 64TH WAY
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-5734
Mailing Address - Country:US
Mailing Address - Phone:954-726-9670
Mailing Address - Fax:
Practice Address - Street 1:4577 WESTON RD
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:FL
Practice Address - Zip Code:33331-3141
Practice Address - Country:US
Practice Address - Phone:954-217-5070
Practice Address - Fax:954-217-5080
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO4055156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician