Provider Demographics
NPI:1629161815
Name:TAN, VIGILIO M (MD)
Entity Type:Individual
Prefix:
First Name:VIGILIO
Middle Name:M
Last Name:TAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 S SPRING STREET
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401
Mailing Address - Country:US
Mailing Address - Phone:304-267-9981
Mailing Address - Fax:304-267-5884
Practice Address - Street 1:219 S SPRING STREET
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401
Practice Address - Country:US
Practice Address - Phone:304-267-9981
Practice Address - Fax:304-267-5884
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV13607207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0096657000Medicaid
WV0096657000Medicaid
D49517Medicare UPIN