Provider Demographics
NPI:1992825061
Name:VEGA, CARLOS JESUS (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:JESUS
Last Name:VEGA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1298 E AVENIDA GRANDE
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85222-1006
Mailing Address - Country:US
Mailing Address - Phone:520-836-1835
Mailing Address - Fax:520-876-4653
Practice Address - Street 1:1298 E AVENIDA GRANDE
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-1006
Practice Address - Country:US
Practice Address - Phone:520-836-1835
Practice Address - Fax:520-876-4653
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1020103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ732421Medicaid