Provider Demographics
NPI:1578639431
Name:LUNA VEGA, ALBERTO SR (MD)
Entity Type:Individual
Prefix:DR
First Name:ALBERTO
Middle Name:
Last Name:LUNA VEGA
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1760 2ND AVE APT 17B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-5392
Mailing Address - Country:US
Mailing Address - Phone:212-369-9620
Mailing Address - Fax:
Practice Address - Street 1:1588 3RD AVE 89TH ST NY NY 10128
Practice Address - Street 2:2146 BEVERLY RD
Practice Address - City:BKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226
Practice Address - Country:US
Practice Address - Phone:212-369-9620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171809174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01729726Medicaid
NY01729726Medicaid
NY065L991Medicare ID - Type Unspecified