Provider Demographics
NPI:1629277306
Name:VEGAS, TOMAS CARLOS (MD)
Entity Type:Individual
Prefix:
First Name:TOMAS
Middle Name:CARLOS
Last Name:VEGAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W. PARK ST.
Mailing Address - Street 2:BWPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:
Practice Address - Street 1:311 W. FAIRCHILD ST.
Practice Address - Street 2:CONVENIENT CARE
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-3803
Practice Address - Country:US
Practice Address - Phone:217-431-7600
Practice Address - Fax:217-431-7850
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01062766A207Q00000X
IL036138260207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00447712OtherRR MEDICARE
IN200868520Medicaid
INP00447712Medicare PIN
IN130910VMedicare PIN
IN854700UUUMedicare PIN
IN252060B6Medicare PIN
INP00447712OtherRR MEDICARE