Provider Demographics
NPI:1538286125
Name:DESERT FAMILY PRACTICE ASSOCOIATES MEDICAL GROUP INC
Entity type:Organization
Organization Name:DESERT FAMILY PRACTICE ASSOCOIATES MEDICAL GROUP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:VIZCARRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-948-1454
Mailing Address - Street 1:11919 HESPERIA RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-1855
Mailing Address - Country:US
Mailing Address - Phone:760-948-1454
Mailing Address - Fax:
Practice Address - Street 1:11919 HESPERIA RD
Practice Address - Street 2:SUITE C
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-1855
Practice Address - Country:US
Practice Address - Phone:760-948-1454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29952207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0050900Medicaid
CAGR0050900Medicaid