Provider Demographics
NPI:1326042672
Name:KIELMOVITCH, IZAK (MD)
Entity Type:Individual
Prefix:DR
First Name:IZAK
Middle Name:
Last Name:KIELMOVITCH
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 1:133 BENMORE DR
Mailing Address - Street 2:STE 100
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-4143
Mailing Address - Country:US
Mailing Address - Phone:407-644-4883
Mailing Address - Fax:407-644-3697
Practice Address - Street 1:133 BENMORE DR
Practice Address - Street 2:STE 100
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32792-4143
Practice Address - Country:US
Practice Address - Phone:407-644-4883
Practice Address - Fax:407-644-3697
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2015-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59630207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
01106345OtherAMERIGROUP
FL054553800Medicaid
ME0059630OtherWORKER'S COMP
040006660OtherRR MEDICARE
040006661OtherRR MEDICARE
12335OtherBLUE CROSS
ME0059630OtherWORKER'S COMP
040006660OtherRR MEDICARE
12335XMedicare ID - Type Unspecified