Provider Demographics
NPI:1750335147
Name:DE LA VEGA, MARA (MD)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:DE LA VEGA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1307 S. INTERNATIONAL PARKWAY
Mailing Address - Street 2:SUITE 2091
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2916
Mailing Address - Country:US
Mailing Address - Phone:407-771-0404
Mailing Address - Fax:407-771-0405
Practice Address - Street 1:1307 S. INTERNATIONAL PARKWAY
Practice Address - Street 2:SUITE 2091
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32806-2916
Practice Address - Country:US
Practice Address - Phone:407-771-0404
Practice Address - Fax:407-771-0405
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73219207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080140852OtherRAILROAD MEDICARE
FL47060OtherBCBS
G37546Medicare UPIN
FL47060OtherBCBS
FL258500600Medicare ID - Type Unspecified