Provider Demographics
NPI:1700638889
Name:VEGA, BETHANY ANN (MD)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:ANN
Last Name:VEGA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5826 BURT RD APT A
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-6377
Mailing Address - Country:US
Mailing Address - Phone:281-790-7984
Mailing Address - Fax:
Practice Address - Street 1:81 WILDCAT WAY BLDG 1525
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29207-6833
Practice Address - Country:US
Practice Address - Phone:903-751-3820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-03
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI00002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program