Basic Information
| Provider Information | |||||||||
| NPI: | 1588013049 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | MEDINA VEGA | ||||||||
| FirstName: | DIANELA | ||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6101 BLUE LAGOON DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331262051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8446300700 | ||||||||
| FaxNumber: | 3055002155 | ||||||||
| Practice Location | |||||||||
| Address1: | 2900 N MILITARY TRL STE 201 | ||||||||
| Address2: | |||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334316308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5612413883 | ||||||||
| FaxNumber: | 5612410025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2016 | ||||||||
| LastUpdateDate: | 12/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 137686 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | ME137686 | 01 | FL | STATE LICENSE | OTHER |