Provider Demographics
NPI:1891886529
Name:IZQUIERDO, OMAR LORENZO (MD)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:LORENZO
Last Name:IZQUIERDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:OMAR
Other - Middle Name:L
Other - Last Name:IZQUIERDO-FRAU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:HATCH
Mailing Address - State:NM
Mailing Address - Zip Code:87937-0370
Mailing Address - Country:US
Mailing Address - Phone:575-267-3280
Mailing Address - Fax:575-267-1747
Practice Address - Street 1:1960 N DATE ST
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901-3701
Practice Address - Country:US
Practice Address - Phone:575-894-7662
Practice Address - Fax:575-894-7930
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2003-0718207P00000X
NMMD2003--0718207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine