Provider Demographics
NPI:1013992536
Name:VIGUILLA, ROBERTO AMPONIN (MD)
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:AMPONIN
Last Name:VIGUILLA
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 1:135 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:ROSCOMMON
Mailing Address - State:MI
Mailing Address - Zip Code:48653-7658
Mailing Address - Country:US
Mailing Address - Phone:989-275-8931
Mailing Address - Fax:989-275-4074
Practice Address - Street 1:135 LAKE ST
Practice Address - Street 2:
Practice Address - City:ROSCOMMON
Practice Address - State:MI
Practice Address - Zip Code:48653-7658
Practice Address - Country:US
Practice Address - Phone:989-275-8931
Practice Address - Fax:989-275-4074
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070945207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4459456Medicaid
MI4550741Medicaid
MI4550741Medicaid
MIH17697Medicare UPIN
MI4459456Medicaid