Provider Demographics
NPI:1265100069
Name:VAG SPECIALIST LLC
Entity type:Organization
Organization Name:VAG SPECIALIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:NIETO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:412-398-5059
Mailing Address - Street 1:401 SE OSCEOLA ST STE 200A
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2503
Mailing Address - Country:US
Mailing Address - Phone:561-318-0252
Mailing Address - Fax:561-744-0735
Practice Address - Street 1:401 SE OSCEOLA ST STE 200A
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2503
Practice Address - Country:US
Practice Address - Phone:561-318-0252
Practice Address - Fax:561-744-0735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-06
Last Update Date:2021-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017290600Medicaid