Healthcare Provider Details

I. General information

NPI: 1780189902
Provider Name (Legal Business Name): IZADORA IZIDORO DIEHL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: IZADORA PORTO IZIDORO

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6405 INITIATIVE BLVD
SARASOTA FL
34240-1249
US

IV. Provider business mailing address

9040 TOWN CENTER PKWY
LAKEWOOD RANCH FL
34202-4101
US

V. Phone/Fax

Practice location:
  • Phone: 941-241-3462
  • Fax: 808-427-9892
Mailing address:
  • Phone: 941-241-3462
  • Fax: 808-427-9892

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME165428
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2020-00312
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: