Healthcare Provider Details

I. General information

NPI: 1114389665
Provider Name (Legal Business Name): FARAH ESTHER VEGA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 JACOBS GULCH RD
KELLOGG ID
83837-2023
US

IV. Provider business mailing address

25 JACOBS GULCH RD
KELLOGG ID
83837-2023
US

V. Phone/Fax

Practice location:
  • Phone: 208-784-1221
  • Fax: 208-784-0961
Mailing address:
  • Phone: 208-784-1221
  • Fax: 208-784-0961

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberM-14866
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: