Provider Demographics
NPI:1518986108
Name:VEGA, EDWARD M (PHD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:M
Last Name:VEGA
Suffix:
Gender:M
Credentials:PHD
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Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:1670 CLAIRMONT RD
Mailing Address - Street 2:ATLANTA VAMC - TRAUMA RECOVERY PROGRAM 116
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-4004
Mailing Address - Country:US
Mailing Address - Phone:404-321-6111
Mailing Address - Fax:
Practice Address - Street 1:1670 CLAIRMONT RD
Practice Address - Street 2:ATLANTA VAMC - TRAUMA RECOVERY PROGRAM 116
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4004
Practice Address - Country:US
Practice Address - Phone:404-321-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPSY-983103TC0700X
GAPSY003088103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN