Basic Information
| Provider Information | |||||||||
| NPI: | 1053775650 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VISCUSE | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | VINCENT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9007 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229069007 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1240 LEE ST | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229080817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4349249333 | ||||||||
| FaxNumber: | 4342447526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2016 | ||||||||
| LastUpdateDate: | 09/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | S4579 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RX0202X | 0101274985 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 421872901 | 05 | TX | MEDICAID | 421872902 | 01 | TX | MEDICAID- CSHCN | OTHER |