Provider Demographics
NPI:1376550947
Name:IZZARD, MARK W (PSY D)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:IZZARD
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1208 WOLFLIN AVE
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-2252
Mailing Address - Country:US
Mailing Address - Phone:806-468-7980
Mailing Address - Fax:806-468-7987
Practice Address - Street 1:1208 WOLFLIN AVE
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-2252
Practice Address - Country:US
Practice Address - Phone:806-468-7980
Practice Address - Fax:806-468-7987
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30789103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0012GDOtherBCBS
TX0012GDOtherBCBS
TX00365EMedicare ID - Type Unspecified