Provider Demographics
NPI:1073172953
Name:VEGA, MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:VEGA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 BARNHILL DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5126
Mailing Address - Country:US
Mailing Address - Phone:317-274-4806
Mailing Address - Fax:
Practice Address - Street 1:350 W 11TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-4108
Practice Address - Country:US
Practice Address - Phone:317-274-4806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.074913207ZP0102X
IN01093022A207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology