Provider Demographics
NPI:1730431065
Name:VEGA, BALTAZAR (OD)
Entity type:Individual
Prefix:DR
First Name:BALTAZAR
Middle Name:
Last Name:VEGA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 S STATE ST STE A265
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-6391
Mailing Address - Country:US
Mailing Address - Phone:801-820-0920
Mailing Address - Fax:
Practice Address - Street 1:560 S STATE ST STE A265
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058
Practice Address - Country:US
Practice Address - Phone:801-820-0920
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-10
Last Update Date:2019-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6779772-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist