Healthcare Provider Details

I. General information

NPI: 1003895566
Provider Name (Legal Business Name): MATIAS JAMES VEGA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 01/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 1ST ST NW ALBUQUERQUE HEALTH CARE FOR THE HOMELESS
ALBUQUERQUE NM
87102-1529
US

IV. Provider business mailing address

1217 1ST ST NW PO BOX 25445
ALBUQUERQUE NM
87102-1529
US

V. Phone/Fax

Practice location:
  • Phone: 505-242-4644
  • Fax: 505-242-3531
Mailing address:
  • Phone: 505-242-4644
  • Fax: 505-242-3531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number98-409
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: