Basic Information
| Provider Information | |||||||||
| NPI: | 1730133745 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VEGA | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4143 CARMICHAEL RD | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361062803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343952200 | ||||||||
| FaxNumber: | 3343952290 | ||||||||
| Practice Location | |||||||||
| Address1: | 1023 MEDICAL CENTER PKWY | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | SELMA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 367016750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342737000 | ||||||||
| FaxNumber: | 3342732386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 11/21/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 24666 | AL | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 009900465 | 05 | AL | MEDICAID | 009935641 | 05 | AL | MEDICAID | 05155792 | 05 | AL | MEDICAID |