Provider Demographics
NPI:1255383188
Name:DESERT FAMILY PRACTICE ASSOCIATES
Entity type:Organization
Organization Name:DESERT FAMILY PRACTICE ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:VIZCARRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-948-1454
Mailing Address - Street 1:11919 HESPERIA RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-1855
Mailing Address - Country:US
Mailing Address - Phone:760-948-1454
Mailing Address - Fax:760-948-6100
Practice Address - Street 1:11919 HESPERIA RD
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1855
Practice Address - Country:US
Practice Address - Phone:760-948-1454
Practice Address - Fax:760-948-6100
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DESERT FAMILY PRACTICE ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-17
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1486207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0050900Medicaid
CAGR0050900Medicaid