Basic Information
| Provider Information | |||||||||
| NPI: | 1558503458 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VEGA | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D., PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1223 GATEWAY DR | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329012607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217254500 | ||||||||
| FaxNumber: | 3219517408 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 HICKORY ST | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329013224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214341771 | ||||||||
| FaxNumber: | 3214341775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2009 | ||||||||
| LastUpdateDate: | 04/01/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | ME 107295 | FL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 245740 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 245740 | 01 | NY | STATE OF NEW YORK | OTHER | ME 107295 | 01 | FL | FLORIDA DEPARTMENT OF HEALTH | OTHER |