Provider Demographics
NPI:1962479238
Name:VEGA, KENNETH JOHN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOHN
Last Name: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 1:1499 WALTON WAY STE 1400
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-2603
Mailing Address - Country:US
Mailing Address - Phone:706-724-6100
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-2761
Practice Address - Country:US
Practice Address - Phone:706-721-8623
Practice Address - Fax:706-721-1459
Is Sole Proprietor?:No
Enumeration Date:2006-03-04
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82094207RG0100X, 207R00000X
CO56528207RG0100X
OK27368207RG0100X
GA079942207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2604078-00Medicaid
FL1000114763OtherRAILROAD MEDICARE
FL2604078-00Medicaid
FL51929ZMedicare PIN
GA000889732AMedicaid
FL2604078-00Medicaid