Basic Information
Provider Information
NPI: 1003001132
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: VIGGIANELLI
FirstName: MICHAEL
MiddleName: ANGELO
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1433 ASHMORE ST
Address2:  
City: SAN LUIS OBISPO
State: CA
PostalCode: 934017682
CountryCode: US
TelephoneNumber: 8055477911
FaxNumber:  
Practice Location
Address1: HWY 1 CALIFORNIA MENS COLONY
Address2:  
City: SAN LUIS OBISPO
State: CA
PostalCode: 934090001
CountryCode: US
TelephoneNumber: 8055477911
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/11/2007
LastUpdateDate: 09/11/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000XA41482CAY Allopathic & Osteopathic PhysiciansFamily Medicine 

No ID Information.


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