Provider Demographics
NPI:1083468169
Name:FERNANDEZ DE LA VEGA, JOAN
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:FERNANDEZ DE LA VEGA
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 1:1600 NE MIAMI GARDENS DR
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33179-4900
Mailing Address - Country:US
Mailing Address - Phone:786-248-5374
Mailing Address - Fax:
Practice Address - Street 1:1600 NE MIAMI GARDENS DR
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33179-4900
Practice Address - Country:US
Practice Address - Phone:786-248-5374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-15
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR024494390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program