Healthcare Provider Details

I. General information

NPI: 1043373111
Provider Name (Legal Business Name): EDRED T VIZCARRA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 6TH AVE SW
RONAN MT
59864-2600
US

IV. Provider business mailing address

48767 ROCKY BUTTE RD
RONAN MT
59864-8897
US

V. Phone/Fax

Practice location:
  • Phone: 406-676-3600
  • Fax: 406-676-3738
Mailing address:
  • Phone: 406-676-0432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number6860
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: