Healthcare Provider Details

I. General information

NPI: 1629502265
Provider Name (Legal Business Name): ANDREW BENJAMIN VIZCARRA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2017
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 SIXTH AVE
SANDPOINT ID
83864-5396
US

IV. Provider business mailing address

301 CEDAR ST STE 206
SANDPOINT ID
83864-1425
US

V. Phone/Fax

Practice location:
  • Phone: 208-263-7101
  • Fax:
Mailing address:
  • Phone: 208-637-1012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number60530
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM-17696
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: