Provider Demographics
NPI:1447427588
Name:VEGA PERALTA, JOSE ANTONIO (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:ANTONIO
Last Name:VEGA PERALTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 14909
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-0909
Mailing Address - Country:US
Mailing Address - Phone:612-871-1114
Mailing Address - Fax:612-870-5491
Practice Address - Street 1:15700 37TH AVE N STE 300
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55446-3661
Practice Address - Country:US
Practice Address - Phone:612-624-5915
Practice Address - Fax:612-624-1473
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN55180207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN18660OtherINTERNAL MEDICINE RESIDENT PERMIT NUMBER