Provider Demographics
NPI:1912429747
Name:VEGA HERNANDEZ, ALFREDO
Entity type:Individual
Prefix:
First Name:ALFREDO
Middle Name:
Last Name:VEGA HERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11000 SW 70TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173-2109
Mailing Address - Country:US
Mailing Address - Phone:786-805-1088
Mailing Address - Fax:786-703-4154
Practice Address - Street 1:11000 SW 70TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-2109
Practice Address - Country:US
Practice Address - Phone:786-805-1088
Practice Address - Fax:786-703-4154
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022407400Medicaid