Provider Demographics
NPI:1629502265
Name:VIZCARRA, ANDREW BENJAMIN (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:BENJAMIN
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 1:301 CEDAR ST STE 206
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-1425
Mailing Address - Country:US
Mailing Address - Phone:208-637-1012
Mailing Address - Fax:
Practice Address - Street 1:810 SIXTH AVE
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-5396
Practice Address - Country:US
Practice Address - Phone:208-263-7101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-19
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN60530208000000X
IDM-17696208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program