1225028624 NPI number — DR. DOMENIC C IZZO JR. M.D.

Table of content: DR. DOMENIC C IZZO JR. M.D. (NPI 1225028624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225028624 NPI number — DR. DOMENIC C IZZO JR. M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IZZO
Provider First Name:
DOMENIC
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
M.D.
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:
1225028624
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1802 PAPERMILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WYOMISSING
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19610-1100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
610-372-0712
Provider Business Mailing Address Fax Number:
610-376-6968

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1802 PAPERMILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WYOMISSING
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19610-1100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-372-0712
Provider Business Practice Location Address Fax Number:
610-376-6968
Provider Enumeration Date:
10/26/2005

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: 207W00000X , with the licence number:  MD029312E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0011323630001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1800009426 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 4338999 . This is a "AETNA" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 01854302 . This is a "CAPITAL BLUE CROSS" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 473979 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0019746000 . This is a "KEYSTONE HEALTH EAST" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".