Healthcare Provider Details

I. General information

NPI: 1982566592
Provider Name (Legal Business Name): DAMIAN IZQUIERDO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

716 FAIRMOUNT PL
BRONX NY
10457-6405
US

IV. Provider business mailing address

271 E 143RD ST APT 1H
BRONX NY
10451-6236
US

V. Phone/Fax

Practice location:
  • Phone: 718-731-3500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number35968
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: