Provider Demographics
NPI:1508444225
Name:VIGO MATOS, JUAN R (MD)
Entity type:Individual
Prefix:DR
First Name:JUAN
Middle Name:R
Last Name:VIGO MATOS
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:PO BOX 421718
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29442-4203
Mailing Address - Country:US
Mailing Address - Phone:843-527-7000
Mailing Address - Fax:
Practice Address - Street 1:606 BLACK RIVER RD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440-3304
Practice Address - Country:US
Practice Address - Phone:843-527-7000
Practice Address - Fax:843-520-8403
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12824207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine