Provider Demographics
NPI:1295797140
Name:VIZCAINO, VANESSA (MD)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:VIZCAINO
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 1:570 ROYAL PALM BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411
Mailing Address - Country:US
Mailing Address - Phone:561-791-3452
Mailing Address - Fax:561-791-6970
Practice Address - Street 1:10115 FOREST HILL BLVD
Practice Address - Street 2:STE 200
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414
Practice Address - Country:US
Practice Address - Phone:561-793-5155
Practice Address - Fax:561-793-4375
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87499207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
296260OtherAVMED
SG075997OtherVISTA
3622791OtherAETNA
48656OtherBCBS
296260OtherAVMED
3622791OtherAETNA
FLP00359614Medicare PIN