Provider Demographics
NPI:1538870696
Name:DE LA VEGA MEDICAL GROUP CORPORATION
Entity type:Organization
Organization Name:DE LA VEGA MEDICAL GROUP CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ARNP-FNP
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:LIZ
Authorized Official - Last Name:DE LA VEGA
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:239-848-9026
Mailing Address - Street 1:225 SANTA BARBARA BLVD
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33991-2032
Mailing Address - Country:US
Mailing Address - Phone:239-848-9026
Mailing Address - Fax:
Practice Address - Street 1:12781 WORLD PLAZA LN BLDG 88
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-7628
Practice Address - Country:US
Practice Address - Phone:239-848-9026
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-09
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty