Provider Demographics
NPI:1588013049
Name:MEDINA VEGA, DIANELA (MD)
Entity Type:Individual
Prefix:
First Name:DIANELA
Middle Name:
Last Name:MEDINA VEGA
Suffix:
Gender:F
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 400
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-2051
Mailing Address - Country:US
Mailing Address - Phone:844-630-0700
Mailing Address - Fax:305-500-2155
Practice Address - Street 1:2900 N MILITARY TRL STE 201
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-6308
Practice Address - Country:US
Practice Address - Phone:561-241-3883
Practice Address - Fax:561-241-0025
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-06
Last Update Date:2021-12-05
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