Provider Demographics
NPI:1457854705
Name:VEGA, JOSHUA JESUS (SFIDC)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:JESUS
Last Name:VEGA
Suffix:
Gender:M
Credentials:SFIDC
Other - Prefix:
Other - First Name:JOSHUA
Other - Middle Name:JESUS
Other - Last Name:VEGA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SFIDC
Mailing Address - Street 1:3265 ADAMS AVE APT 46
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-1650
Mailing Address - Country:US
Mailing Address - Phone:772-359-4373
Mailing Address - Fax:
Practice Address - Street 1:34101 FARENHOLT AVE BLDG 14
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-7000
Practice Address - Country:US
Practice Address - Phone:772-359-4373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty CorpsmanGroup - Single Specialty