Basic Information
| Provider Information | |||||||||
| NPI: | 1124383716 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CANCIO VEGA | ||||||||
| FirstName: | CARIDAD | ||||||||
| MiddleName: | MAYTE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8400 NW 33RD ST | ||||||||
| Address2: | |||||||||
| City: | DORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331222008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7864088502 | ||||||||
| FaxNumber: | 7866217815 | ||||||||
| Practice Location | |||||||||
| Address1: | 18610 NW 87TH AVE | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8446654827 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2012 | ||||||||
| LastUpdateDate: | 11/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME123483 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 015089100 | 05 | FL | MEDICAID |