Provider Demographics
NPI:1952330441
Name:VEGA, JOSE G (PHD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:G
Last Name:VEGA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 SPRING BRANCH ST
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-7540
Mailing Address - Country:US
Mailing Address - Phone:719-671-7441
Mailing Address - Fax:719-544-8442
Practice Address - Street 1:1522 W FRANK AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3334
Practice Address - Country:US
Practice Address - Phone:719-544-8520
Practice Address - Fax:719-544-8442
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX38725103G00000X, 103TM1800X, 103T00000X, 103T00000X, 103TM1800X
CO818103TF0200X
TX387103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
9540-6Medicare ID - Type Unspecified
R21336Medicare UPIN