Provider Demographics
NPI:1790488443
Name:VEGA, EDGAR JESUS
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:JESUS
Last Name:VEGA
Suffix:
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 1:6911 CONVOY CT FL 2
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-1014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6911 CONVOY CT FL 2
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-1014
Practice Address - Country:US
Practice Address - Phone:760-871-5856
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-22
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program