Provider Demographics
NPI:1730346628
Name:VANEGAS, MYRIAM FABIOLA
Entity type:Individual
Prefix:
First Name:MYRIAM
Middle Name:FABIOLA
Last Name:VANEGAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1067 OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-4601
Mailing Address - Country:US
Mailing Address - Phone:718-466-3220
Mailing Address - Fax:
Practice Address - Street 1:1067 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452-4601
Practice Address - Country:US
Practice Address - Phone:718-466-3220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYDEA NO 664207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine