Provider Demographics
NPI:1750329140
Name:KIZZART, JEROME DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:DOUGLAS
Last Name:KIZZART
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 1:923 10TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FLORESVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78114-1851
Mailing Address - Country:US
Mailing Address - Phone:830-299-4040
Mailing Address - Fax:281-826-2598
Practice Address - Street 1:1004 S SAINT MARYS ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78205-3413
Practice Address - Country:US
Practice Address - Phone:830-299-4040
Practice Address - Fax:281-826-2598
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2014-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH3823207P00000X, 207PE0005X, 207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8V1922OtherBCBS
TXP00382498OtherMEDICARE RAILROAD
TX8V1922OtherBCBS
TXP00382498OtherMEDICARE RAILROAD
TXE07192Medicare UPIN
TX8F4473Medicare PIN
TX8F8760Medicare PIN