Healthcare Provider Details

I. General information

NPI: 1467724286
Provider Name (Legal Business Name): IVETTE VIGODA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2012
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4422 3RD AVE
BRONX NY
10457-2545
US

IV. Provider business mailing address

4422 3RD AVE
BRONX NY
10457-2545
US

V. Phone/Fax

Practice location:
  • Phone: 718-960-6205
  • Fax:
Mailing address:
  • Phone: 718-960-6205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number275674
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: