Provider Demographics
NPI:1881149706
Name:IZQUIERDO, RAUL JR
Entity type:Individual
Prefix:MR
First Name:RAUL
Middle Name:
Last Name:IZQUIERDO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 CORTELYOU RD
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11226-5607
Mailing Address - Country:US
Mailing Address - Phone:718-940-1212
Mailing Address - Fax:718-462-4098
Practice Address - Street 1:1509 CORTELYOU RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-5607
Practice Address - Country:US
Practice Address - Phone:718-940-1212
Practice Address - Fax:718-462-4098
Is Sole Proprietor?:No
Enumeration Date:2016-08-20
Last Update Date:2016-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY47-2871756172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver