Healthcare Provider Details

I. General information

NPI: 1376748475
Provider Name (Legal Business Name): VINCENT VIGILANTE MEDICAL DOCTOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5162 SEARSVILLE RD
PINE BUSH NY
12566-6421
US

IV. Provider business mailing address

PO BOX 698 5162 SEARSVILLE RD
PINE BUSH NY
12566-0698
US

V. Phone/Fax

Practice location:
  • Phone: 845-744-3392
  • Fax: 845-744-3392
Mailing address:
  • Phone: 845-744-3392
  • Fax: 845-744-3392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA1402121
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: