Provider Demographics
NPI:1760588768
Name:IZEN, BRENDA GAIL (MD)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:GAIL
Last Name:IZEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2638 HIGHWAY 109 STE 101
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1161
Mailing Address - Country:US
Mailing Address - Phone:636-821-2500
Mailing Address - Fax:636-821-2210
Practice Address - Street 1:2638 HIGHWAY 109 STE 101
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040-1161
Practice Address - Country:US
Practice Address - Phone:636-821-2500
Practice Address - Fax:636-821-2210
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR2K89207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOE50424Medicare UPIN
001014246Medicare ID - Type Unspecified