Provider Demographics
NPI:1629275474
Name:VIGILIA, LARRY P
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:P
Last Name:VIGILIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 E COLORADO ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1308
Mailing Address - Country:US
Mailing Address - Phone:818-356-1141
Mailing Address - Fax:818-547-4392
Practice Address - Street 1:1141 E COLORADO ST
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1308
Practice Address - Country:US
Practice Address - Phone:818-956-1141
Practice Address - Fax:818-547-4392
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38814207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA38814BMedicare PIN
CAA38814Medicare PIN