Healthcare Provider Details

I. General information

NPI: 1013947662
Provider Name (Legal Business Name): TITO LAMONT IZARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 N DR MARTIN LUTHER KING JR DR
MILWAUKEE WI
53212-2709
US

IV. Provider business mailing address

2555 N MARTIN LUTHER KING DR MILWAUKEE HEALTH SERVICES INC
MILWAUKEE WI
53212-2709
US

V. Phone/Fax

Practice location:
  • Phone: 414-372-8080
  • Fax: 414-464-6321
Mailing address:
  • Phone: 414-372-8080
  • Fax: 414-372-1705

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number39584-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: