Provider Demographics
NPI:1700775210
Name:VIRGILLE, ISABEL THERESA (OD)
Entity type:Individual
Prefix:
First Name:ISABEL
Middle Name:THERESA
Last Name:VIRGILLE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 NE 201ST TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33179-5143
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:GRAND FORKS AFB
Practice Address - Street 2:1599 J STREET
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58205
Practice Address - Country:US
Practice Address - Phone:701-747-5601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-30
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL152W00000X152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist