Healthcare Provider Details

I. General information

NPI: 1487412854
Provider Name (Legal Business Name): ETHAN IZU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 E ERIE ST
CHICAGO IL
60611-3167
US

IV. Provider business mailing address

355 E ERIE ST
CHICAGO IL
60611-3167
US

V. Phone/Fax

Practice location:
  • Phone: 312-238-1000
  • Fax:
Mailing address:
  • Phone: 312-238-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number125.087144
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: