Provider Demographics
NPI:1497029565
Name:VIZCARRA-FALLA, LUIS RAFAEL (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:RAFAEL
Last Name:VIZCARRA-FALLA
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 1:7082 ROSELAKE CIR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-1680
Mailing Address - Country:US
Mailing Address - Phone:404-438-6568
Mailing Address - Fax:
Practice Address - Street 1:6825 JIMMY CARTER BLVD
Practice Address - Street 2:SUITE 1590
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-1228
Practice Address - Country:US
Practice Address - Phone:678-615-2565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-06
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
282N00000X
GA68630207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No282N00000XHospitalsGeneral Acute Care Hospital