Provider Demographics
NPI:1790066983
Name:DE LA VEGA PEDIATRICS, CORP.
Entity Type:Organization
Organization Name:DE LA VEGA PEDIATRICS, CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TATIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:DE LA VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-277-5877
Mailing Address - Street 1:12781 WORLD PLAZA LN STE 1
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-4078
Mailing Address - Country:US
Mailing Address - Phone:239-277-5877
Mailing Address - Fax:239-277-1354
Practice Address - Street 1:12781 WORLD PLAZA LN STE 1
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-4078
Practice Address - Country:US
Practice Address - Phone:239-277-5877
Practice Address - Fax:239-277-1354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-01
Last Update Date:2023-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME101292208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty