Healthcare Provider Details

I. General information

NPI: 1750329140
Provider Name (Legal Business Name): JEROME DOUGLAS KIZZART MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 11/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 S SAINT MARYS ST
SAN ANTONIO TX
78205-3413
US

IV. Provider business mailing address

923 10TH ST SUITE 101
FLORESVILLE TX
78114-1851
US

V. Phone/Fax

Practice location:
  • Phone: 830-299-4040
  • Fax: 281-826-2598
Mailing address:
  • Phone: 830-299-4040
  • Fax: 281-826-2598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberH3823
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207PE0005X
TaxonomyUndersea and Hyperbaric Medicine (Emergency Medicine) Physician
License NumberH3823
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberH3823
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberH3823
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: