Provider Demographics
NPI:1427065473
Name:VIZCARRA, LOURDES (MD)
Entity type:Individual
Prefix:
First Name:LOURDES
Middle Name:
Last Name:VIZCARRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:LOURDES
Other - Middle Name:
Other - Last Name:VIZCARRA WURZEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2350 ALAMO AVE SE SUITE 160
Mailing Address - Street 2:MSC11 6295
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2350 ALAMO AVE SE STE 160
Practice Address - Street 2:MSC11 6295
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-3225
Practice Address - Country:US
Practice Address - Phone:505-925-2350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2002-0496207Q00000X
AZ31251207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM37234374Medicaid
NMH79159Medicare UPIN
NM37234374Medicaid