Provider Demographics
NPI:1659398592
Name:VEGA, LUIS (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:VEGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LUIS
Other - Middle Name:
Other - Last Name:VEGA-TORRES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:121 E FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:COLON
Mailing Address - State:MI
Mailing Address - Zip Code:49040-9363
Mailing Address - Country:US
Mailing Address - Phone:269-432-3221
Mailing Address - Fax:269-432-3120
Practice Address - Street 1:121 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:COLON
Practice Address - State:MI
Practice Address - Zip Code:49040
Practice Address - Country:US
Practice Address - Phone:269-432-3221
Practice Address - Fax:269-432-3120
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILV080959207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI21611OtherHEALTH PLAN OF MICHIGAN
MI4782700Medicaid
MI01-31372OtherPHYSICIANS HEALTH PLAN
MI0807510341OtherBLUE CROSS BLUE SHIELD
MI155177OtherGREAT LAKES HEALTH PLAN
MIP00266151Medicare PIN
MI01-31372OtherPHYSICIANS HEALTH PLAN
MIP23180002Medicare PIN