Healthcare Provider Details

I. General information

NPI: 1730012881
Provider Name (Legal Business Name): ROBERT VIGIL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2026
Last Update Date: 06/08/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

326 A SOUTH MCCURDY RD
ESPANOLA NM
87532
US

IV. Provider business mailing address

PO BOX 1360 326 A SOUTH MCCURDY RD
PENA BLANCA NM
87041-1360
US

V. Phone/Fax

Practice location:
  • Phone: 505-630-7853
  • Fax:
Mailing address:
  • Phone: 505-630-7853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1435
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: