Provider Demographics
NPI:1891729752
Name:VIZCARRA PA, CARLOS ANDRES (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:ANDRES
Last Name:VIZCARRA PA
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:13000 US HIGHWAY 1
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SEBASTIAN
Mailing Address - State:FL
Mailing Address - Zip Code:32958-3773
Mailing Address - Country:US
Mailing Address - Phone:772-589-9188
Mailing Address - Fax:772-589-9187
Practice Address - Street 1:13000 US HIGHWAY 1
Practice Address - Street 2:SUITE 4
Practice Address - City:SEBASTIAN
Practice Address - State:FL
Practice Address - Zip Code:32958-3773
Practice Address - Country:US
Practice Address - Phone:772-589-9188
Practice Address - Fax:772-589-9187
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME 93719207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL7739516OtherEIN