=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255576310
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IZQUIERDO-GASTROENTEROLOGY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2008
-----------------------------------------------------
Last Update Date | 12/03/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3757 91ST ST
-----------------------------------------------------
City | JACKSON HEIGHTS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11372-7901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-779-7697
-----------------------------------------------------
Fax | 718-457-2402
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3757 91ST ST
-----------------------------------------------------
City | JACKSON HEIGHTS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11372-7901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-779-7697
-----------------------------------------------------
Fax | 718-457-2402
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL OFFICEFR
-----------------------------------------------------
Name | DR. THOMAS JOEL IZQUIERDO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 718-779-7697
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0800X
-----------------------------------------------------
Taxonomy Name | Endoscopy Clinic/Center
-----------------------------------------------------
License Number | 156124
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------