MEDICARE: TOMAS CARLOS VEGAS M.D.

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	01062766A	IN
2	207Q00000X	Family Medicine Physician	036138260	IL

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00447712	OTHER	IN	RR MEDICARE

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1629277306
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TOMAS CARLOS VEGAS M.D.

Provider Business Mailing Address
First Line	:	611 W. PARK ST.
Second Line	:	BWPC
City	:	URBANA
State	:	IL
Zip	:	61801-2500
Country	:	US
Telephone Number	:	217-383-6792
Fax Number	:

Provider Business Practice Location Address
First Line	:	311 W. FAIRCHILD ST.
Second Line	:	CONVENIENT CARE
City	:	DANVILLE
State	:	IL
Zip	:	61832-3803
Country	:	US
Telephone Number	:	217-431-7600
Fax Number	:	217-431-7850

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2007
Last Update Date	:	11/13/2015

311 W. FAIRCHILD STREET
DANVILLE, IL
61832-3803

Practice Phone: 217-431-7900
Practice Fax: 217-431-7634

311 W. FAIRCHILD ST.
DANVILLE, IL
61832-3803