Provider Demographics
NPI:1558503458
Name:VEGA, JOSE LUIS (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:LUIS
Last Name:VEGA
Suffix:
Gender:M
Credentials:MD, PHD
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Mailing Address - Street 1:1223 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-2607
Mailing Address - Country:US
Mailing Address - Phone:321-725-4500
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:1350 HICKORY ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3224
Practice Address - Country:US
Practice Address - Phone:321-434-1771
Practice Address - Fax:321-434-1775
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-24
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY2457402084N0400X
FLME 1072952084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME 107295OtherFLORIDA DEPARTMENT OF HEALTH
NY245740OtherSTATE OF NEW YORK