Basic Information
Provider Information | |||||||||
NPI: | 1649206087 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VIZCARRA | ||||||||
FirstName: | ROSA | ||||||||
MiddleName: | ISELA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GARCIA | ||||||||
OtherFirstName: | ROSA | ||||||||
OtherMiddleName: | ISELA AMAYA | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 7622 LOUIS PASTEUR DR | ||||||||
Address2: | STE 201 | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782294037 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2106103859 | ||||||||
FaxNumber: | 2106412277 | ||||||||
Practice Location | |||||||||
Address1: | 7622 LOUIS PASTEUR DR | ||||||||
Address2: | STE 201 | ||||||||
City: | SAN ANTONIO | ||||||||
State: | TX | ||||||||
PostalCode: | 782294037 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2106103859 | ||||||||
FaxNumber: | 2106412277 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/25/2006 | ||||||||
LastUpdateDate: | 04/27/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M9722 | TX | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207QG0300X | M9722 | TX | Y |   | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine |
ID Information
ID | Type | State | Issuer | Description | 184189205 | 05 | TX |   | MEDICAID | 315067YMVU | 01 | TX | WNI | OTHER |