Provider Demographics
NPI:1740389261
Name:IZSAK, ELIEZER MOSHE (MD)
Entity Type:Individual
Prefix:
First Name:ELIEZER
Middle Name:MOSHE
Last Name:IZSAK
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 1:425 S 11TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4239
Mailing Address - Country:US
Mailing Address - Phone:863-679-9494
Mailing Address - Fax:863-679-8866
Practice Address - Street 1:425 S 11TH ST STE 1
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4239
Practice Address - Country:US
Practice Address - Phone:863-679-9494
Practice Address - Fax:863-679-8866
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME36693207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL53619Medicare ID - Type Unspecified
FLE15801Medicare UPIN