Provider Demographics
NPI:1598120909
Name:VEGA, IDAMARIS (B A)
Entity Type:Individual
Prefix:
First Name:IDAMARIS
Middle Name:
Last Name:VEGA
Suffix:
Gender:F
Credentials:B A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 HIGH ST STE 230
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01105-1435
Mailing Address - Country:US
Mailing Address - Phone:413-885-3864
Mailing Address - Fax:
Practice Address - Street 1:511 E COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01105-2506
Practice Address - Country:US
Practice Address - Phone:413-827-8959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-30
Last Update Date:2020-12-04
Deactivation Date:2020-09-18
Deactivation Code:
Reactivation Date:2020-11-20
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker