Provider Demographics
NPI:1770980476
Name:VEGA, JOSE JESUS III (LMT)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:JESUS
Last Name:VEGA
Suffix:III
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1684 VILLAGE GRN
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:MD
Mailing Address - Zip Code:21114-2059
Mailing Address - Country:US
Mailing Address - Phone:443-938-1201
Mailing Address - Fax:
Practice Address - Street 1:1684 VILLAGE GRN
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-2059
Practice Address - Country:US
Practice Address - Phone:443-938-1201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-24
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDM04706225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist