Provider Demographics
NPI: | 1710046206 |
---|---|
Name: | VISCARDI, MARJORIE E (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | MARJORIE |
Middle Name: | E |
Last Name: | VISCARDI |
Suffix: | |
Gender: | F |
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: | 706 W BEN WHITE BLVD |
Mailing Address - Street 2: | STE A |
Mailing Address - City: | AUSTIN |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 78704-8144 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 512-334-2509 |
Mailing Address - Fax: | 512-334-2589 |
Practice Address - Street 1: | 5701 W SLAUGHTER LN BLDG C |
Practice Address - Street 2: | |
Practice Address - City: | AUSTIN |
Practice Address - State: | TX |
Practice Address - Zip Code: | 78749-6528 |
Practice Address - Country: | US |
Practice Address - Phone: | 512-334-2509 |
Practice Address - Fax: | 512-334-2589 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-12-08 |
Last Update Date: | 2023-03-07 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AZ | 54566 | 207Q00000X |
TX | J2400 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 135951509 | Medicaid | |
TX | J2400 | Other | MEDICAL LICENSE |
TX | P01330571 | Other | RRMC PTAN |
TX | P01330571 | Other | RRMC PTAN |
TX | F92919 | Medicare UPIN | |
TX | 135951509 | Medicaid |