1346245917 NPI number — DR. EDWARD G IZZO JR. MD

Table of content: DR. EDWARD G IZZO JR. MD (NPI 1346245917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346245917 NPI number — DR. EDWARD G IZZO JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IZZO
Provider First Name:
EDWARD
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346245917
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1901 HAVERFORD AVE
Provider Second Line Business Mailing Address:
STE 105
Provider Business Mailing Address City Name:
SUN CITY CENTER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33573-5200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-258-4533
Provider Business Mailing Address Fax Number:
813-258-4733

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1901 HAVERFORD AVE
Provider Second Line Business Practice Location Address:
STE 105
Provider Business Practice Location Address City Name:
SUN CITY CENTER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33573-5200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-258-4533
Provider Business Practice Location Address Fax Number:
813-258-4733
Provider Enumeration Date:
06/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X , with the licence number:  ME0060860 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086S0127X , with the licence number: ME0060860 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208G00000X , with the licence number: ME0060860 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2463923 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 058349900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 14356 . This is a "IND BX" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 330005522 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: ME0060860 . This is a "LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 593689604 . This is a "TAX ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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