Provider Demographics
NPI:1629182662
Name:IZQUIERDO, ERNESTO L (MD)
Entity Type:Individual
Prefix:DR
First Name:ERNESTO
Middle Name:L
Last Name:IZQUIERDO
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 1:1781 PARK CENTER DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-6254
Mailing Address - Country:US
Mailing Address - Phone:407-297-3626
Mailing Address - Fax:407-297-3772
Practice Address - Street 1:1781 PARK CENTER DRIVE
Practice Address - Street 2:SUITE 120
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835
Practice Address - Country:US
Practice Address - Phone:407-297-3626
Practice Address - Fax:407-297-3772
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 95729207P00000X, 2080N0001X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276498900Medicaid
NYF95911Medicare UPIN
FL276498900Medicaid