Basic Information
| Provider Information | |||||||||
| NPI: | 1235144940 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIGOR | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | NELSON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5938 BUTTONWOOD DR | ||||||||
| Address2: | |||||||||
| City: | HASLETT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488409757 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173396405 | ||||||||
| FaxNumber: | 5173396405 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 N CENTER ST | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493311212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168978473 | ||||||||
| FaxNumber: | 6168970081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 4301051646 | MI | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0802X | 4301051646 | MI | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry | 2084P0805X | 4301051646 | MI | X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 0330457 | 01 | MI | BLUE CROSS/BLUE SHIELD | OTHER | P00092490 | 01 | MI | RAILROAD MEDICARE | OTHER | 4301051646 | 01 | MI | STATE OF MICHIGAN LICENSE | OTHER |