Healthcare Provider Details

I. General information

NPI: 1366494015
Provider Name (Legal Business Name): CARLOS R VIGIL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7974 HAVEN AVE SUITE 210
RANCHO CUCAMONGA CA
91730
US

IV. Provider business mailing address

7974 HAVEN AVE SUITE 210
RANCHO CUCAMONGA CA
91730
US

V. Phone/Fax

Practice location:
  • Phone: 909-941-0661
  • Fax: 909-948-5577
Mailing address:
  • Phone: 909-941-0661
  • Fax: 909-948-5577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20A7446
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: