Provider Demographics
NPI:1922178391
Name:VIZINAS, EDMUND WALTER (MD)
Entity Type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:WALTER
Last Name:VIZINAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MRS
Other - First Name:GRAZINA
Other - Middle Name:RITA
Other - Last Name:VIZINAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:6918 W ARCHER AVE
Mailing Address - Street 2:3 AND 4
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-2337
Mailing Address - Country:US
Mailing Address - Phone:773-229-9965
Mailing Address - Fax:773-229-9849
Practice Address - Street 1:6918 W ARCHER AVE
Practice Address - Street 2:3 AND 4
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2337
Practice Address - Country:US
Practice Address - Phone:773-229-9965
Practice Address - Fax:773-229-9849
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-159443207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCD7818OtherMEDICARE RR
IL1710102660OtherMEDICARE ID-TYPE UNSPECIFIED
IL363326542OtherTRICARE
IL1710102660OtherBCBS
IL036059443Medicaid
IL229840Medicare PIN
IL1710102660OtherBCBS