Basic Information
| Provider Information | |||||||||
| NPI: | 1033119854 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VEGA | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 530062 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303530062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436956071 | ||||||||
| FaxNumber: | 8435695881 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 MAPLE ST W | ||||||||
| Address2: | |||||||||
| City: | HAMPTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299243238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039433813 | ||||||||
| FaxNumber: | 8039435971 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2005 | ||||||||
| LastUpdateDate: | 06/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 23033 | SC | N | Allopathic & Osteopathic Physicians | Hospitalist | 207Q00000X | 23033 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00846508 | 01 | SC | RR MEDICARE | OTHER | 230333 | 05 | SC | MEDICAID | GP5367 | 01 | SC | MEDICAID GROUP | OTHER | GP5421 | 01 | SC | GROUP MEDICAID | OTHER |