Provider Demographics
NPI:1508444225
Name:VIGO MATOS, JUAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:R
Last Name:VIGO MATOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1230 BAXTER ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-3712
Mailing Address - Country:US
Mailing Address - Phone:706-389-3860
Mailing Address - Fax:706-389-3861
Practice Address - Street 1:1500 OGLETHORPE AVE STE 200D
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2165
Practice Address - Country:US
Practice Address - Phone:706-389-3875
Practice Address - Fax:706-389-3876
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12824207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine