Basic Information
| Provider Information | |||||||||
| NPI: | 1184795155 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIGIL | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | V. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455631 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1920 COLORADO AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA MONICA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 904043414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103194700 | ||||||||
| FaxNumber: | 3104535106 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 11/25/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | G76613 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207Q00000X | G76613 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1184795155 | 05 | CA | MEDICAID |