Healthcare Provider Details

I. General information

NPI: 1639247604
Provider Name (Legal Business Name): RONALD STEPHEN VIGIL O.D., F.A.A.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 11/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7009 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87109-1598
US

IV. Provider business mailing address

4235 ALTURA VISTA LN NE
ALBUQUERQUE NM
87110-5064
US

V. Phone/Fax

Practice location:
  • Phone: 505-883-2550
  • Fax: 505-881-8931
Mailing address:
  • Phone: 505-266-6082
  • Fax: 505-881-8931

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number491
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: