1235210287 NPI number — RAFAEL A GONZALEZ-VIZOSO MD

Table of content: RAFAEL A GONZALEZ-VIZOSO MD (NPI 1235210287)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235210287 NPI number — RAFAEL A GONZALEZ-VIZOSO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GONZALEZ-VIZOSO
Provider First Name:
RAFAEL
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235210287
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 S 336TH ST
Provider Second Line Business Mailing Address:
SUITE 600
Provider Business Mailing Address City Name:
FEDERAL WAY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98003-6328
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
180-033-6861
Provider Business Mailing Address Fax Number:
253-838-6418

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3455 S 344TH WAY
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
FEDERAL WAY
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98001-9560
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
180-033-6861
Provider Business Practice Location Address Fax Number:
253-838-6418
Provider Enumeration Date:
10/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  MD00033490 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5971GO . This is a "BSWA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8187320 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00370054 . This is a "RRGA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0213580 . This is a "LIWA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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