Provider Demographics
NPI:1134741705
Name:VIGNOLO, FANNY ESMERALDA (RT(R)(CT)(MR)(ARRT)
Entity type:Individual
Prefix:
First Name:FANNY
Middle Name:ESMERALDA
Last Name:VIGNOLO
Suffix:
Gender:F
Credentials:RT(R)(CT)(MR)(ARRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 NW 25TH ST STE 3D
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33172-1416
Mailing Address - Country:US
Mailing Address - Phone:800-972-9114
Mailing Address - Fax:866-236-5409
Practice Address - Street 1:9600 NW 25TH ST STE 3D
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33172-1416
Practice Address - Country:US
Practice Address - Phone:800-972-9114
Practice Address - Fax:866-236-5409
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-17
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCRT546582085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCRT54658OtherDOH