Provider Demographics
NPI:1689178519
Name:VEGA, MARISA CHRISTINA-CORNEJO
Entity Type:Individual
Prefix:
First Name:MARISA
Middle Name:CHRISTINA-CORNEJO
Last Name:VEGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 EUCLID AVE # A81
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0001
Mailing Address - Country:US
Mailing Address - Phone:216-444-6337
Mailing Address - Fax:216-636-5129
Practice Address - Street 1:9500 EUCLID AVE # A81
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-2401
Practice Address - Country:US
Practice Address - Phone:216-444-6337
Practice Address - Fax:216-636-5129
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-23
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.145237207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program