Provider Demographics
NPI:1134415888
Name:VEGA GONZALEZ, MYRIAM LUCIA
Entity type:Individual
Prefix:DR
First Name:MYRIAM
Middle Name:LUCIA
Last Name:VEGA GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:MYRIAM
Other - Middle Name:L
Other - Last Name:VEGA PENSO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:410-933-6423
Mailing Address - Fax:410-500-4266
Practice Address - Street 1:601 N CAROLINE ST # 8072
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0006
Practice Address - Country:US
Practice Address - Phone:410-955-5933
Practice Address - Fax:410-502-2309
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT196728207N00000X
MDD94940207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology