Healthcare Provider Details

I. General information

NPI: 1205449626
Provider Name (Legal Business Name): KEVIN IZQUIERDO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2020
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3422A COURT ST
PEKIN IL
61554-6235
US

IV. Provider business mailing address

3422A COURT ST
PEKIN IL
61554-6235
US

V. Phone/Fax

Practice location:
  • Phone: 309-477-6000
  • Fax: 309-477-6001
Mailing address:
  • Phone: 309-477-6000
  • Fax: 309-477-6001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036182098
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number125.086053
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number036182098
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: