Healthcare Provider Details

I. General information

NPI: 1033293220
Provider Name (Legal Business Name): VIGILANT MEDICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 11/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 N BRENT ST
VENTURA CA
93003-2809
US

IV. Provider business mailing address

3116 W MARCH LN SUITE 200
STOCKTON CA
95219-2369
US

V. Phone/Fax

Practice location:
  • Phone: 209-473-6555
  • Fax:
Mailing address:
  • Phone: 209-473-6555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG53093
License Number StateCA

VIII. Authorized Official

Name: DR. DANIEL A. WAXER
Title or Position: OWNER
Credential: M.D.
Phone: 209-473-6555