Healthcare Provider Details

I. General information

NPI: 1306895602
Provider Name (Legal Business Name): JUAN CARLOS VEGA SOLIVEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 MASONIC DR CHRISTUS CABRINI GROUP PRACTICE INTENSIVISTS
ALEXANDRIA LA
71301-3841
US

IV. Provider business mailing address

919 HIDDEN RDG
IRVING TX
75038-3813
US

V. Phone/Fax

Practice location:
  • Phone: 318-448-6700
  • Fax: 318-483-4066
Mailing address:
  • Phone: 469-282-2711
  • Fax: 469-282-0996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberMD12724R
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD.12724R
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberMD12724R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: