Healthcare Provider Details

I. General information

NPI: 1306106000
Provider Name (Legal Business Name): WILSON IZQUIERDO MD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2012
Last Update Date: 05/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 S WATERMAN AVE SUITE F / URGENT FAMILY CENTER
SAN BERNARDINO CA
92408-2877
US

IV. Provider business mailing address

1850 S WATERMAN AVE SUITE F / URGENT FAMILY CENTER
SAN BERNARDINO CA
92408-2877
US

V. Phone/Fax

Practice location:
  • Phone: 909-890-9393
  • Fax:
Mailing address:
  • Phone: 909-890-9393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberA117127
License Number StateCA

VIII. Authorized Official

Name: DR. WILSON IZQUIERDO
Title or Position: PHYSICIAN
Credential: MD
Phone: 909-289-4947