Healthcare Provider Details

I. General information

NPI: 1467453746
Provider Name (Legal Business Name): GREGORY S. VIGESAA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 04/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 NEAL ZICK RD
WILLARD OH
44890-9287
US

IV. Provider business mailing address

PO BOX 636388
CINCINNATI OH
45263-0001
US

V. Phone/Fax

Practice location:
  • Phone: 419-964-5038
  • Fax:
Mailing address:
  • Phone: 419-251-2053
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35-05-7088-V
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: