=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760567762
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEORGE L. VEGA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2006
-----------------------------------------------------
Last Update Date | 02/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4933 UNIVERSITY BLVD W
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32216-5935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-733-7800
-----------------------------------------------------
Fax | 904-419-4888
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 E BAY ST STE 606
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32202-2948
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-556-3991
-----------------------------------------------------
Fax | 904-356-8027
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | ME51364
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------