Provider Demographics
NPI:1003867763
Name:VIZCAINO, EDGAR M (MD)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:M
Last Name:VIZCAINO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 W TILGHMAN ST
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18104-4354
Mailing Address - Country:US
Mailing Address - Phone:494-221-9136
Mailing Address - Fax:484-221-9130
Practice Address - Street 1:865 E 4TH ST
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18015-1935
Practice Address - Country:US
Practice Address - Phone:484-221-9136
Practice Address - Fax:484-221-9130
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4500442084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABV8837532OtherDEA
PABV8837532OtherDEA
KS104003Medicare ID - Type Unspecified