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General NPI Number Information
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NPI Number | 1497237036
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Entity Type | Organization
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Legal Business Name | LEO VIGNE MD PC
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Dates
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Enumeration Date | 08/30/2018
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Last Update Date | 01/04/2024
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Provider Practice Location Address
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Address Line | 106 W 105TH ST APT 16
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City | NEW YORK
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State | NY
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Zip | 10025-8802
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Country | US
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Telephone | 917-733-0344
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Fax |
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Provider Business Mailing Address
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Address Line | 106 W 105TH ST APT 16
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City | NEW YORK
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State | NY
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Zip | 10025-8802
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Country | US
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Telephone | 917-733-0344
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LEO GARY BONILLA JR.
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Credential | MD
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Telephone | 347-374-0554
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number | 207239-1
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License Number State | NY
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