Healthcare Provider Details

I. General information

NPI: 1508831926
Provider Name (Legal Business Name): KEVIN DWAYNE IZARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2006
Last Update Date: 07/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13700 W NATIONAL AVE SUITE 128
NEW BERLIN WI
53151-9521
US

IV. Provider business mailing address

2856 N GRANT BLVD
MILWAUKEE WI
53210-2424
US

V. Phone/Fax

Practice location:
  • Phone: 414-217-4909
  • Fax: 978-291-1897
Mailing address:
  • Phone: 414-871-7250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38516
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: