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General NPI Number Information
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NPI Number | 1083028898
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Entity Type | Organization
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Legal Business Name | FREDERICK J DE LA VEGA, MD
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Dates
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Enumeration Date | 06/19/2014
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Last Update Date | 06/19/2014
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Provider Practice Location Address
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Address Line | 9834 GENESEE AVE 411
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City | LA JOLLA
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State | CA
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Zip | 92037-1223
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Country | US
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Telephone | 858-677-1755
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Fax | 858-677-1771
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Provider Business Mailing Address
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Address Line | 23052 ALICIA PKWY # 619
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City | MISSION VIEJO
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State | CA
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Zip | 92692-1643
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Country | US
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Telephone | 714-808-9797
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Fax | 714-808-9393
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Authorized Official
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Title or Position | OWNER
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Name | DR. FREDERICK J. DE LA VEGA
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Credential | M.D.
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Telephone | 858-677-1755
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A81923
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License Number State | CA
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