Provider Demographics
NPI:1336689892
Name:VEGA, GISELL (MD)
Entity Type:Individual
Prefix:
First Name:GISELL
Middle Name:
Last Name:VEGA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:26908 INDEPENDENCE WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:EVANS MILLS
Mailing Address - State:NY
Mailing Address - Zip Code:13637-3301
Mailing Address - Country:US
Mailing Address - Phone:315-629-4525
Mailing Address - Fax:315-629-5751
Practice Address - Street 1:120 HOBART ST
Practice Address - Street 2:RESIDENCY PROGRAM
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-4308
Practice Address - Country:US
Practice Address - Phone:315-801-1149
Practice Address - Fax:315-801-3565
Is Sole Proprietor?:No
Enumeration Date:2017-03-03
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY306562207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program