Provider Demographics
NPI:1518946805
Name:DE LA VEGA, RAUL STEPHEN III (MD)
Entity Type:Individual
Prefix:DR
First Name:RAUL
Middle Name:STEPHEN
Last Name:DE LA VEGA
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:222 N LAFAYETTE ST
Mailing Address - Street 2:SUITE 01
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-4444
Mailing Address - Country:US
Mailing Address - Phone:704-482-3880
Mailing Address - Fax:704-487-0294
Practice Address - Street 1:222 N LAFAYETTE ST
Practice Address - Street 2:SUITE 01
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-4444
Practice Address - Country:US
Practice Address - Phone:704-482-3880
Practice Address - Fax:704-487-0294
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC245842085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8928077Medicaid
NC24584OtherNC MEDICAL LICENSE
SCN24584Medicaid
NC28077OtherNC BLUE CROSS BLUE SHIELD
NC28077OtherNC BLUE CROSS BLUE SHIELD
NC24584OtherNC MEDICAL LICENSE
SCN24584Medicaid
2151913NMedicare ID - Type Unspecified