Provider Demographics
NPI:1881779478
Name:VIZCARRONDO, MANUEL (MD)
Entity type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:
Last Name:VIZCARRONDO
Suffix:
Gender:M
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:PO BOX 2342
Mailing Address - Street 2:
Mailing Address - City:GUAYAMA
Mailing Address - State:PR
Mailing Address - Zip Code:00785-2342
Mailing Address - Country:US
Mailing Address - Phone:787-824-6392
Mailing Address - Fax:
Practice Address - Street 1:59 BALDORIOTY
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:PR
Practice Address - Zip Code:00751
Practice Address - Country:US
Practice Address - Phone:787-824-6392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8733302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR$$$$$$$$$Medicaid