Provider Demographics
NPI:1417085309
Name:VIGNALI, SERGIO JUAN (MD)
Entity type:Individual
Prefix:
First Name:SERGIO
Middle Name:JUAN
Last Name:VIGNALI
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:PO BOX 935921
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-5921
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:305 MEMORIAL MEDICAL PKWY STE 400
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5169
Practice Address - Country:US
Practice Address - Phone:386-231-3580
Practice Address - Fax:386-672-3311
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.087342207V00000X
FLME97991207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000256300Medicaid
OH0076178Medicaid
FL000256300Medicaid
OHH135420Medicare PIN