Basic Information
| Provider Information | |||||||||
| NPI: | 1083028898 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FREDERICK J DE LA VEGA, MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23052 ALICIA PKWY | ||||||||
| Address2: | # 619 | ||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926921643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148089797 | ||||||||
| FaxNumber: | 7148089393 | ||||||||
| Practice Location | |||||||||
| Address1: | 9834 GENESEE AVE | ||||||||
| Address2: | 411 | ||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920371223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586771755 | ||||||||
| FaxNumber: | 8586771771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2014 | ||||||||
| LastUpdateDate: | 06/19/2014 | ||||||||
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| AuthorizedOfficialLastName: | DE LA VEGA | ||||||||
| AuthorizedOfficialFirstName: | FREDERICK | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8586771755 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | A81923 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.