Provider Demographics
NPI:1285762377
Name:VIGIL, JOHNNIE R (MD)
Entity type:Individual
Prefix:DR
First Name:JOHNNIE
Middle Name:R
Last Name:VIGIL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:R
Other - Last Name:VIGIL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:10753 PROSPECT AVE NE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-3272
Mailing Address - Country:US
Mailing Address - Phone:505-323-8911
Mailing Address - Fax:505-294-3305
Practice Address - Street 1:10700 MENAUL BLVD NE
Practice Address - Street 2:SUITE C
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-2437
Practice Address - Country:US
Practice Address - Phone:505-323-8911
Practice Address - Fax:505-294-3305
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM89-319208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NME58183Medicare UPIN