Provider Demographics
NPI:1770115057
Name:TIRU VEGA, MARILEE ALEJANDRA
Entity type:Individual
Prefix:
First Name:MARILEE
Middle Name:ALEJANDRA
Last Name:TIRU VEGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 801426
Mailing Address - Street 2:
Mailing Address - City:COTO LAUREL
Mailing Address - State:PR
Mailing Address - Zip Code:00780-1426
Mailing Address - Country:US
Mailing Address - Phone:787-407-0059
Mailing Address - Fax:
Practice Address - Street 1:4TA EXT EL MONTE
Practice Address - Street 2:CORDOVA ST C82
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00730
Practice Address - Country:US
Practice Address - Phone:787-407-0059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-05
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6411627390200000X
PR36166208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program