Basic Information
Provider Information | |||||||||
NPI: | 1629182662 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | IZQUIERDO | ||||||||
FirstName: | ERNESTO | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1781 PARK CENTER DR | ||||||||
Address2: | SUITE 120 | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328356254 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4072973626 | ||||||||
FaxNumber: | 4072973772 | ||||||||
Practice Location | |||||||||
Address1: | 1781 PARK CENTER DRIVE | ||||||||
Address2: | SUITE 120 | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 32835 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4072973626 | ||||||||
FaxNumber: | 4072973772 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/18/2006 | ||||||||
LastUpdateDate: | 12/16/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME 95729 | FL | N |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 2080N0001X | ME 95729 | FL | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 208D00000X | ME 95729 | FL | Y |   | Allopathic & Osteopathic Physicians | General Practice |   |
ID Information
ID | Type | State | Issuer | Description | 276498900 | 05 | FL |   | MEDICAID |