Provider Demographics
NPI:1639247604
Name:VIGIL, RONALD STEPHEN (OD, FAAO)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:STEPHEN
Last Name:VIGIL
Suffix:
Gender:M
Credentials:OD, FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4235 ALTURA VISTA LN NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-5064
Mailing Address - Country:US
Mailing Address - Phone:505-266-6082
Mailing Address - Fax:505-881-8931
Practice Address - Street 1:7009 MONTGOMERY BLVD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-1598
Practice Address - Country:US
Practice Address - Phone:505-883-2550
Practice Address - Fax:505-881-8931
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM491152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP00793469Medicare PIN
NM0598510001Medicare NSC
NM349229601Medicare PIN
NMU77010Medicare UPIN