Provider Demographics
NPI:1376748475
Name:VIGILANTE, VINCENT (MEDICAL DOCTOR)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:
Last Name:VIGILANTE
Suffix:
Gender:M
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 698
Mailing Address - Street 2:5162 SEARSVILLE RD
Mailing Address - City:PINE BUSH
Mailing Address - State:NY
Mailing Address - Zip Code:12566-0698
Mailing Address - Country:US
Mailing Address - Phone:845-744-3392
Mailing Address - Fax:845-744-3392
Practice Address - Street 1:5162 SEARSVILLE RD
Practice Address - Street 2:
Practice Address - City:PINE BUSH
Practice Address - State:NY
Practice Address - Zip Code:12566-6421
Practice Address - Country:US
Practice Address - Phone:845-744-3392
Practice Address - Fax:845-744-3392
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYA1402121208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
BV3961756OtherDEA
56A351Medicare PIN
A63268Medicare UPIN