Provider Demographics
NPI:1851363337
Name:DELA VEGA, SOFRONIO B (MD)
Entity Type:Individual
Prefix:DR
First Name:SOFRONIO
Middle Name:B
Last Name:DELA VEGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 MORRISON DRIVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15216-1206
Mailing Address - Country:US
Mailing Address - Phone:412-343-8521
Mailing Address - Fax:
Practice Address - Street 1:464 MORRISON DR
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15216-1206
Practice Address - Country:US
Practice Address - Phone:412-343-8521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD033855L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000746400Medicaid
PAC30244Medicare UPIN
PA000746400Medicaid