Provider Demographics
NPI:1407512163
Name:VIZCARRA, ANDREW JORGE
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JORGE
Last Name:VIZCARRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3631 S HARBOR BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92704-7936
Mailing Address - Country:US
Mailing Address - Phone:657-356-6490
Mailing Address - Fax:657-356-6290
Practice Address - Street 1:3631 S HARBOR BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-7936
Practice Address - Country:US
Practice Address - Phone:657-356-6490
Practice Address - Fax:657-356-6290
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker