Provider Demographics
NPI:1063455699
Name:IZE-LUDLOW, DIEGO (MD)
Entity Type:Individual
Prefix:
First Name:DIEGO
Middle Name:
Last Name:IZE-LUDLOW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 S WOOD ST
Mailing Address - Street 2:MC 856
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4325
Mailing Address - Country:US
Mailing Address - Phone:312-996-1795
Mailing Address - Fax:312-996-8218
Practice Address - Street 1:840 S WOOD ST
Practice Address - Street 2:MC 856
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4325
Practice Address - Country:US
Practice Address - Phone:312-996-1795
Practice Address - Fax:312-996-8218
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4221602080P0205X
IL0361180392080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAI72196Medicare UPIN