Provider Demographics
NPI:1881955169
Name:VEGA, JOSE LUIS III (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:LUIS
Last Name:VEGA
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2060 W 24TH ST
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-6123
Mailing Address - Country:US
Mailing Address - Phone:928-819-8834
Mailing Address - Fax:928-539-5579
Practice Address - Street 1:675 S AVENUE B
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-2749
Practice Address - Country:US
Practice Address - Phone:928-539-3140
Practice Address - Fax:928-782-5296
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-04
Last Update Date:2019-02-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ54496207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ303915Medicaid