Provider Demographics
NPI:1275794430
Name:VEGA, DAVID (MT)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:VEGA
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:LABORATORIO CLINICO
Other - Middle Name:
Other - Last Name:DR. AGUSTIN STAHL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:21-20 CARR 174
Mailing Address - Street 2:SANTA ROSA
Mailing Address - City:BAYAMON
Mailing Address - State:PR
Mailing Address - Zip Code:00959-6512
Mailing Address - Country:US
Mailing Address - Phone:787-787-1691
Mailing Address - Fax:787-740-1770
Practice Address - Street 1:21-20 CARR 174
Practice Address - Street 2:SANTA ROSA
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00959-6512
Practice Address - Country:US
Practice Address - Phone:787-787-1691
Practice Address - Fax:787-740-1770
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-20
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR473291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR38303Medicare PIN