Provider Demographics
NPI:1407944663
Name:IZQUIERDO, MICHAEL R (DC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:IZQUIERDO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14524 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-4317
Mailing Address - Country:US
Mailing Address - Phone:216-521-7777
Mailing Address - Fax:216-521-7778
Practice Address - Street 1:14524 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4317
Practice Address - Country:US
Practice Address - Phone:216-521-7777
Practice Address - Fax:216-521-7778
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3664111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4175402Medicare PIN