Provider Demographics
NPI:1629079173
Name:IZZI, STEPHAN ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:STEPHAN
Middle Name:ROBERT
Last Name:IZZI
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 1:7575 RITCHIE HWY
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-8951
Mailing Address - Country:US
Mailing Address - Phone:410-766-1444
Mailing Address - Fax:410-766-9453
Practice Address - Street 1:7575 RITCHIE HWY
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-8951
Practice Address - Country:US
Practice Address - Phone:410-766-1444
Practice Address - Fax:410-766-9453
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0025782207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD41551201OtherBSMD
637AMedicare ID - Type Unspecified
B67259Medicare UPIN