Provider Demographics
NPI:1932844040
Name:DE LA VEGA, RAUL JOSE (MD)
Entity type:Individual
Prefix:DR
First Name:RAUL
Middle Name:JOSE
Last Name:DE LA 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 1:8004 NW 154TH ST STE 102
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5814
Mailing Address - Country:US
Mailing Address - Phone:305-529-8517
Mailing Address - Fax:
Practice Address - Street 1:8251 W BROWARD BLVD STE 103
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-2703
Practice Address - Country:US
Practice Address - Phone:954-255-7310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-03
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME169833207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine