Provider Demographics
NPI:1295960268
Name:SANTIAGO VEGA, JUAN G (17561)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:G
Last Name:SANTIAGO VEGA
Suffix:
Gender:M
Credentials:17561
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC03
Mailing Address - Street 2:BOX13437
Mailing Address - City:PENUELAS
Mailing Address - State:PR
Mailing Address - Zip Code:00624
Mailing Address - Country:US
Mailing Address - Phone:787-836-2216
Mailing Address - Fax:
Practice Address - Street 1:HC03
Practice Address - Street 2:BOX 13437
Practice Address - City:PENUELAS
Practice Address - State:PR
Practice Address - Zip Code:00624
Practice Address - Country:US
Practice Address - Phone:787-836-2216
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-20
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR17561208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice