Provider Demographics
NPI:1659016657
Name:DE LA VEGA, JESUS ERNESTO JR
Entity Type:Individual
Prefix:
First Name:JESUS
Middle Name:ERNESTO
Last Name:DE LA VEGA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5140 BALTIMORE DR APT 144
Mailing Address - Street 2:ADDRESS LINE 2
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942
Mailing Address - Country:US
Mailing Address - Phone:760-457-5094
Mailing Address - Fax:
Practice Address - Street 1:13255 BLACK MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-2658
Practice Address - Country:US
Practice Address - Phone:858-484-7241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86113183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist