Provider Demographics
NPI:1689019812
Name:VIGIL DOMBECK, MARK JEFFREY (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JEFFREY
Last Name:VIGIL DOMBECK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:JEFFREY
Other - Last Name:DOMBECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1402 PARK ST STE G
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-4562
Mailing Address - Country:US
Mailing Address - Phone:510-900-5123
Mailing Address - Fax:888-974-4218
Practice Address - Street 1:1402 PARK ST STE G
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-4562
Practice Address - Country:US
Practice Address - Phone:510-900-5123
Practice Address - Fax:888-974-4218
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2017-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY25695103T00000X, 103TB0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral