Basic Information
| Provider Information | |||||||||
| NPI: | 1003867763 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VIZCAINO | ||||||||
| FirstName: | EDGAR | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2030 W TILGHMAN ST | ||||||||
| Address2: | |||||||||
| City: | ALLENTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 181044354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4942219136 | ||||||||
| FaxNumber: | 4842219130 | ||||||||
| Practice Location | |||||||||
| Address1: | 865 E 4TH ST | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180151935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4842219136 | ||||||||
| FaxNumber: | 4842219130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2006 | ||||||||
| LastUpdateDate: | 12/10/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MD450044 | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | BV8837532 | 01 | PA | DEA | OTHER |