Basic Information
| Provider Information | |||||||||
| NPI: | 1396061859 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VEGA | ||||||||
| FirstName: | JUAN | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3301 W FOREST HOME AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532152843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627412000 | ||||||||
| FaxNumber: | 2627412180 | ||||||||
| Practice Location | |||||||||
| Address1: | W3985 COUNTY ROAD NN | ||||||||
| Address2: | |||||||||
| City: | ELKHORN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531214337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627412000 | ||||||||
| FaxNumber: | 2627412180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2010 | ||||||||
| LastUpdateDate: | 01/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LC0200X | 57028 | WI | N | Allopathic & Osteopathic Physicians | Anesthesiology | Critical Care Medicine | 207L00000X | 57028 | WI | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 100034034 | 05 | WI | MEDICAID | 1396061859 | 05 | WI | MEDICAID |