Provider Demographics
NPI:1568086908
Name:MARTINEZ-VEGA, WALLIE (DO)
Entity Type:Individual
Prefix:
First Name:WALLIE
Middle Name:
Last Name:MARTINEZ-VEGA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1648 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-4922
Mailing Address - Country:US
Mailing Address - Phone:610-674-4550
Mailing Address - Fax:610-674-4554
Practice Address - Street 1:1648 S 4TH ST
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18103-4922
Practice Address - Country:US
Practice Address - Phone:610-674-4550
Practice Address - Fax:610-674-4554
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT020274207Q00000X
PAOS023090207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine