Healthcare Provider Details

I. General information

NPI: 1679788012
Provider Name (Legal Business Name): DR. MARISOL VEGA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

AVE.65 INF. BO. SAN ANTON PARQUE ESCORIAL LOTE #3
CAROLINA PR
00985
US

IV. Provider business mailing address

PORTAL DE LOS PINOS RR36 BOX 19
SAN JUAN PR
00926
US

V. Phone/Fax

Practice location:
  • Phone: 787-757-6850
  • Fax:
Mailing address:
  • Phone: 787-760-8932
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number10366
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: