Provider Demographics
NPI:1760476303
Name:IZAH, AUGUSTINE I (MD)
Entity Type:Individual
Prefix:
First Name:AUGUSTINE
Middle Name:I
Last Name:IZAH
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 1:5857 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-2666
Mailing Address - Country:US
Mailing Address - Phone:219-884-4450
Mailing Address - Fax:
Practice Address - Street 1:5857 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-2666
Practice Address - Country:US
Practice Address - Phone:219-884-4450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-09
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042994207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200044580Medicaid
G09773Medicare UPIN
IN229600AMedicare ID - Type Unspecified