Healthcare Provider Details

I. General information

NPI: 1992768469
Provider Name (Legal Business Name): DALE E VIZCARRA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 04/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MAC LANE AVERA MEDICAL GROUP PIERRE
PIERRE SD
57501
US

IV. Provider business mailing address

100 MAC LANE AVERA MEDICAL GROUP PIERRE
PIERRE SD
57501
US

V. Phone/Fax

Practice location:
  • Phone: 605-224-5901
  • Fax: 605-945-5096
Mailing address:
  • Phone: 605-224-5901
  • Fax: 605-945-5096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number3600
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberSD3600
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: