Provider Demographics
NPI:1588660963
Name:VEGA SOTO, JOSUE M (PHD)
Entity Type:Individual
Prefix:MR
First Name:JOSUE
Middle Name:M
Last Name:VEGA SOTO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 140501
Mailing Address - Street 2:CALLE MANUEL PEREZ FREYKZ #256
Mailing Address - City:ARECIBO
Mailing Address - State:PR
Mailing Address - Zip Code:00614
Mailing Address - Country:US
Mailing Address - Phone:787-536-0922
Mailing Address - Fax:
Practice Address - Street 1:CALLE MANUEL PEREZ FREYTEZ #256
Practice Address - Street 2:
Practice Address - City:ARECIBO
Practice Address - State:PR
Practice Address - Zip Code:00614
Practice Address - Country:US
Practice Address - Phone:787-536-0922
Practice Address - Fax:787-879-1934
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2012-09-13
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
PR1881174400000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0055429Medicare ID - Type Unspecified
PRP91859Medicare UPIN