Provider Demographics
NPI:1588013049
Name:MEDINA VEGA, DIANELA (MD)
Entity type:Individual
Prefix:
First Name:DIANELA
Middle Name:
Last Name:MEDINA VEGA
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6101 BLUE LAGOON DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-3168
Mailing Address - Country:US
Mailing Address - Phone:844-630-0700
Mailing Address - Fax:305-500-2155
Practice Address - Street 1:5643 NW 29TH ST
Practice Address - Street 2:
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-1531
Practice Address - Country:US
Practice Address - Phone:954-979-6900
Practice Address - Fax:866-245-0079
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-06
Last Update Date:2025-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL137686207Q00000X
PR14117-I390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME137686OtherSTATE LICENSE