1407842735 NPI number — GRETCHEN E VIGIL MD

Table of content: GRETCHEN E VIGIL MD (NPI 1407842735)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407842735 NPI number — GRETCHEN E VIGIL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VIGIL
Provider First Name:
GRETCHEN
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GISSLEN
Provider Other First Name:
GRETCHEN
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1407842735
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 HAWKINS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IOWA CITY
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52242-1009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
319-356-8558
Provider Business Mailing Address Fax Number:
319-356-4855

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 HAWKINS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IOWA CITY
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52242-1009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-356-8558
Provider Business Practice Location Address Fax Number:
319-356-4855
Provider Enumeration Date:
09/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  33405 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 18411 . This is a "WELLMARK BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: 0210658 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".




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