Provider Demographics
NPI:1992768469
Name:VIZCARRA, DALE E (MD)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:E
Last Name:VIZCARRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 MAC LANE
Mailing Address - Street 2:AVERA MEDICAL GROUP PIERRE
Mailing Address - City:PIERRE
Mailing Address - State:SD
Mailing Address - Zip Code:57501
Mailing Address - Country:US
Mailing Address - Phone:605-224-5901
Mailing Address - Fax:605-945-5096
Practice Address - Street 1:100 MAC LANE
Practice Address - Street 2:AVERA MEDICAL GROUP PIERRE
Practice Address - City:PIERRE
Practice Address - State:SD
Practice Address - Zip Code:57501
Practice Address - Country:US
Practice Address - Phone:605-224-5901
Practice Address - Fax:605-945-5096
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SD3600207Q00000X
SDSD3600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5609172Medicaid
SD5609170Medicaid
SD103055Medicare PIN
SDE93169Medicare UPIN
SD5609172Medicaid