MEDICARE: JEROME DOUGLAS KIZZART MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	H3823	TX
2	207PE0005X	Undersea and Hyperbaric Medicine (Emergency Medicine) Physician	H3823	TX
3	207R00000X	Internal Medicine Physician	H3823	TX
4	208M00000X	Hospitalist Physician	H3823	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00382498	OTHER	TX	MEDICARE RAILROAD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8V1922	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1750329140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEROME DOUGLAS KIZZART MD

Provider Business Mailing Address
First Line	:	923 10TH ST
Second Line	:	SUITE 101
City	:	FLORESVILLE
State	:	TX
Zip	:	78114-1851
Country	:	US
Telephone Number	:	830-299-4040
Fax Number	:	281-826-2598

Provider Business Practice Location Address
First Line	:	1004 S SAINT MARYS ST
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78205-3413
Country	:	US
Telephone Number	:	830-299-4040
Fax Number	:	281-826-2598

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	11/29/2014

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Directions to “ JEROME DOUGLAS KIZZART MD” Practice Location

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