Provider Demographics
NPI:1629182662
Name:IZQUIERDO, ERNESTO LAZARO (MD)
Entity type:Individual
Prefix:DR
First Name:ERNESTO
Middle Name:LAZARO
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:PO BOX 878
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33836-0878
Mailing Address - Country:US
Mailing Address - Phone:689-223-3898
Mailing Address - Fax:689-223-3898
Practice Address - Street 1:712 53RD AVE E STE C
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203-5827
Practice Address - Country:US
Practice Address - Phone:417-552-4569
Practice Address - Fax:877-788-3881
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME95729208D00000X
FLME 957292080N0001X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276498900Medicaid
NYF95911Medicare UPIN
FL276498900Medicaid