Provider Demographics
NPI:1922361641
Name:IZQUIERDO, KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
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 1:2315 STOCKTON BLVD # OP512
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2201
Mailing Address - Country:US
Mailing Address - Phone:916-734-2724
Mailing Address - Fax:
Practice Address - Street 1:10535 HOSPITAL WAY
Practice Address - Street 2:
Practice Address - City:MATHER
Practice Address - State:CA
Practice Address - Zip Code:95655-4200
Practice Address - Country:US
Practice Address - Phone:916-843-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME135454208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARES000Medicare UPIN