Provider Demographics
NPI:1235332362
Name:VISTA, JEANNIE URQUICO (MD)
Entity Type:Individual
Prefix:DR
First Name:JEANNIE
Middle Name:URQUICO
Last Name:VISTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JEANNIE
Other - Middle Name:MANGUERA
Other - Last Name:URQUICO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6555 COYLE AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-0303
Mailing Address - Country:US
Mailing Address - Phone:916-965-4612
Mailing Address - Fax:
Practice Address - Street 1:6555 COYLE AVE STE 310
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0303
Practice Address - Country:US
Practice Address - Phone:916-965-4612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100182208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics