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General NPI Number Information
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NPI Number | 1750335147
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Entity Type | Individual
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Provider Name | MARA DE LA VEGA MD
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Gender | Female
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Dates
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Enumeration Date | 05/20/2006
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Last Update Date | 12/08/2008
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Provider Practice Location Address
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Address Line | 1307 S. INTERNATIONAL PARKWAY SUITE 2091
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City | LAKE MARY
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State | FL
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Zip | 32806-2916
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Country | US
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Telephone | 407-771-0404
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Fax | 407-771-0405
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Provider Business Mailing Address
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Address Line | 1307 S. INTERNATIONAL PARKWAY SUITE 2091
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City | LAKE MARY
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State | FL
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Zip | 32806-2916
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Country | US
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Telephone | 407-771-0404
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Fax | 407-771-0405
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | ME73219
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License Number State | FL
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