Provider Demographics
NPI:1124322193
Name:VEGA SANTIAGO, AGUSTIN (MD)
Entity type:Individual
Prefix:DR
First Name:AGUSTIN
Middle Name:
Last Name:VEGA SANTIAGO
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 1:4691 OLD CANOE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-1550
Mailing Address - Country:US
Mailing Address - Phone:407-498-4015
Mailing Address - Fax:
Practice Address - Street 1:4691 OLD CANOE CREEK RD
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-1550
Practice Address - Country:US
Practice Address - Phone:407-498-4015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 127343207R00000X
PR18052208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice