Healthcare Provider Details

I. General information

NPI: 1497659502
Provider Name (Legal Business Name): LUIS GUILLERMO DE JESUS III VEGA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81-37 CALLE 68
BAYAMON PR
00961-4522
US

IV. Provider business mailing address

158 AVE CAMPOBELLO
CIDRA PR
00739-1579
US

V. Phone/Fax

Practice location:
  • Phone: 939-401-4401
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003239
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: