Provider Demographics
NPI:1073647269
Name:DESERT FAMILY PRACTICE ASSOCIATES
Entity Type:Organization
Organization Name:DESERT FAMILY PRACTICE ASSOCIATES
Other - Org Name:FAMILY PRACTICE ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JORDAN
Authorized Official - Last Name:VIZCARRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-948-1454
Mailing Address - Street 1:11919 HESPERIA RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-1855
Mailing Address - Country:US
Mailing Address - Phone:760-948-1454
Mailing Address - Fax:760-948-6100
Practice Address - Street 1:15863 KASOTA RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-4507
Practice Address - Country:US
Practice Address - Phone:760-256-3864
Practice Address - Fax:760-256-7378
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DESERT FAMILY PRACTICE ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-16
Last Update Date:2015-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00000843207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0050902Medicaid
CAGR0050902Medicaid
CAZZZ37917ZMedicare ID - Type Unspecified