Provider Demographics
NPI:1427152016
Name:VEGA, CHARLES P (MD)
Entity type:Individual
Prefix:
First Name:CHARLES P
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:PRIMARY CARE MEDICAL GROUP
Mailing Address - Street 2:PO BOX 513620
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-3620
Mailing Address - Country:US
Mailing Address - Phone:714-456-6369
Mailing Address - Fax:
Practice Address - Street 1:UCI FAMILY HEALTH CENTER
Practice Address - Street 2:800 N MAIN STREET
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701
Practice Address - Country:US
Practice Address - Phone:714-456-8978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA000000A63796207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA63796CMedicare PIN
CAWA63796BMedicare PIN