Provider Demographics
NPI:1407530348
Name:DE LA VEGA, RAFAEL ANTONIO (MD)
Entity Type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:ANTONIO
Last Name:DE LA VEGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7864 NW 171ST ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-3842
Mailing Address - Country:US
Mailing Address - Phone:305-332-1089
Mailing Address - Fax:
Practice Address - Street 1:7000 SW 62ND AVE STE 600
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4728
Practice Address - Country:US
Practice Address - Phone:305-909-9805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLHSE208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice