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General NPI Number Information
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NPI Number | 1790066983
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Entity Type | Organization
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Legal Business Name | DE LA VEGA PEDIATRICS, CORP.
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Dates
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Enumeration Date | 09/01/2011
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Last Update Date | 03/25/2023
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Provider Practice Location Address
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Address Line | 12781 WORLD PLAZA LN STE 1
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City | FORT MYERS
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State | FL
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Zip | 33907-4078
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Country | US
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Telephone | 239-277-5877
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Fax | 239-277-1354
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Provider Business Mailing Address
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Address Line | 12781 WORLD PLAZA LN STE 1
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City | FORT MYERS
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State | FL
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Zip | 33907-4078
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Country | US
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Telephone | 239-277-5877
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Fax | 239-277-1354
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | TATIANA DE LA VEGA
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Credential |
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Telephone | 239-277-5877
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | ME101292
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | ME101292
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License Number State | FL
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