Healthcare Provider Details

I. General information

NPI: 1033119854
Provider Name (Legal Business Name): LUIS R VEGA M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MAPLE ST W
HAMPTON SC
29924-3238
US

IV. Provider business mailing address

PO BOX 530062
ATLANTA GA
30353-0062
US

V. Phone/Fax

Practice location:
  • Phone: 803-943-3813
  • Fax: 803-943-5971
Mailing address:
  • Phone: 843-695-6071
  • Fax: 843-569-5881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number23033
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23033
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: