Provider Demographics
NPI:1932179363
Name:VISOT, LUIS R (MD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:R
Last Name:VISOT
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 1:300 SCHUYLKILL MEDICAL PLZ
Mailing Address - Street 2:
Mailing Address - City:POTTSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17901-3668
Mailing Address - Country:US
Mailing Address - Phone:570-621-9500
Mailing Address - Fax:570-621-9510
Practice Address - Street 1:300 SCH MEDICAL PLAZA
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901
Practice Address - Country:US
Practice Address - Phone:570-621-9500
Practice Address - Fax:570-621-9510
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD035845E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001060620Medicaid
PAC33313Medicare UPIN