1659398592 NPI number — LUIS VEGA M.D.

Table of content: LUIS VEGA M.D. (NPI 1659398592)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659398592 NPI number — LUIS VEGA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VEGA
Provider First Name:
LUIS
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VEGA-TORRES
Provider Other First Name:
LUIS
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1659398592
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
121 E FRANKLIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49040-9363
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-432-3221
Provider Business Mailing Address Fax Number:
269-432-3120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 FRANKLIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-432-3221
Provider Business Practice Location Address Fax Number:
269-432-3120
Provider Enumeration Date:
07/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  LV080959 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 21611 . This is a "HEALTH PLAN OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4782700 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 01-31372 . This is a "PHYSICIANS HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0807510341 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 155177 . This is a "GREAT LAKES HEALTH PLAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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