Provider Demographics
NPI:1235534215
Name:IZQUIERDO DIAZ, JOSE ANTONIO (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:ANTONIO
Last Name:IZQUIERDO DIAZ
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 1:10280 SW STEPHANIE WAY # 8-101
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-0000
Mailing Address - Country:US
Mailing Address - Phone:786-389-6304
Mailing Address - Fax:
Practice Address - Street 1:10280 SW STEPHANIE WAY # 8-101
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-1962
Practice Address - Country:US
Practice Address - Phone:786-389-6304
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-03
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY100021299390200000X
FL130827207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1235534215Medicaid