Provider Demographics
NPI:1962597112
Name:VIZINA, PENNY P (OD)
Entity type:Individual
Prefix:DR
First Name:PENNY
Middle Name:P
Last Name:VIZINA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MS
Other - First Name:PENNY
Other - Middle Name:LYNN
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:2560 HARVEST LN
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-4305
Mailing Address - Country:US
Mailing Address - Phone:507-451-3072
Mailing Address - Fax:507-451-4291
Practice Address - Street 1:2560 HARVEST LN
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-4305
Practice Address - Country:US
Practice Address - Phone:507-451-3072
Practice Address - Fax:507-451-4291
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003736152W00000X
MN2381152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3108975Medicaid
900A760100OtherBLUE CROSS AND BLUE SHIELD
900A760100OtherBLUE CROSS AND BLUE SHIELD
MI3108975Medicaid
0A761010004Medicare ID - Type Unspecified