Provider Demographics
NPI:1538122015
Name:VIZCARRA, RODNEY T (MD)
Entity Type:Individual
Prefix:DR
First Name:RODNEY
Middle Name:T
Last Name:VIZCARRA
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 1:100 MAC LANE
Mailing Address - Street 2:AVERA MEDICAL GROUP PIERRE
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501
Mailing Address - Country:US
Mailing Address - Phone:605-945-5202
Mailing Address - Fax:605-945-5094
Practice Address - Street 1:100 MAC LANE
Practice Address - Street 2:AVERA MEDICAL GROUP PIERRE
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501
Practice Address - Country:US
Practice Address - Phone:605-945-5202
Practice Address - Fax:605-945-5094
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDSD3621208600000X
SD3621208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7301310Medicaid
SD7301312Medicaid
SD7301312Medicaid
SD7301310Medicaid
SDF35685Medicare UPIN