Basic Information
Provider Information
NPI: 1942331731
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: VIZCARRONDO
FirstName: MAYRA
MiddleName: Y
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 29134
Address2: PEDIATRIA GENERAL RCM
City: SAN JUAN
State: PR
PostalCode: 009290134
CountryCode: US
TelephoneNumber: 7877564010
FaxNumber: 7877773227
Practice Location
Address1: CENTRO MEDICO DE PR BO MONACILLOS
Address2: DEPARTAMENTO DE PEDIATRIA, OFICINA 1 A-29
City: SAN JUAN
State: PR
PostalCode: 00936
CountryCode: US
TelephoneNumber: 7877564020
FaxNumber: 7877773227
Other Information
ProviderEnumerationDate: 03/07/2007
LastUpdateDate: 10/11/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208000000X11243PRY Allopathic & Osteopathic PhysiciansPediatrics 

No ID Information.


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