Provider Demographics
NPI:1871505651
Name:VEGA, MARTIN
Entity Type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:
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:N15 CALLE ALMENDRO
Mailing Address - Street 2:SANTA CLARA
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969-6828
Mailing Address - Country:US
Mailing Address - Phone:787-790-2424
Mailing Address - Fax:787-790-2424
Practice Address - Street 1:N15 CALLE ALMENDRO
Practice Address - Street 2:SANTA CLARA
Practice Address - City:GUAYNABO
Practice Address - State:PR
Practice Address - Zip Code:00969-6828
Practice Address - Country:US
Practice Address - Phone:787-790-2424
Practice Address - Fax:787-790-2424
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR7146208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR7146OtherSTATE MEDICAL LICENSE
PR20081Medicare ID - Type Unspecified
PRH61314Medicare UPIN