Provider Demographics
NPI:1619068095
Name:LAGO, VICENTE (MD PA)
Entity Type:Individual
Prefix:
First Name:VICENTE
Middle Name:
Last Name:LAGO
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 NW 42ND AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-5683
Mailing Address - Country:US
Mailing Address - Phone:305-541-1041
Mailing Address - Fax:305-541-7762
Practice Address - Street 1:351 NW 42ND AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-5683
Practice Address - Country:US
Practice Address - Phone:305-541-1041
Practice Address - Fax:305-541-7762
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0024854207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL037706600Medicaid
FL95141Medicare ID - Type Unspecified
FL037706600Medicaid