Provider Demographics
NPI:1417250804
Name:JEFFREY S. IZENBERG, DO, LTD
Entity Type:Organization
Organization Name:JEFFREY S. IZENBERG, DO, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:IZENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:928-532-8386
Mailing Address - Street 1:5171 CUB LAKE RD STE B210
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7866
Mailing Address - Country:US
Mailing Address - Phone:928-537-9844
Mailing Address - Fax:
Practice Address - Street 1:5171 CUB LAKE RD STE B210
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7866
Practice Address - Country:US
Practice Address - Phone:928-532-8386
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-07
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ653561Medicaid