Provider Demographics
NPI:1497237036
Name:LEO VIGNE MD PC
Entity Type:Organization
Organization Name:LEO VIGNE MD PC
Other - Org Name:LEO VIGNE MD PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:BONILLA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:347-374-0554
Mailing Address - Street 1:106 W 105TH ST APT 16
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-8802
Mailing Address - Country:US
Mailing Address - Phone:917-733-0344
Mailing Address - Fax:
Practice Address - Street 1:106 W 105TH ST APT 16
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-8802
Practice Address - Country:US
Practice Address - Phone:917-733-0344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-30
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207239-1207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty