Provider Demographics
NPI:1063455699
Name:IZE-LUDLOW, DIEGO (MD)
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:
Last Name:IZE-LUDLOW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9143 N JEREMY RD
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84098-4892
Mailing Address - Country:US
Mailing Address - Phone:385-315-1345
Mailing Address - Fax:
Practice Address - Street 1:81 S MARIO CAPECCHI DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-5888
Practice Address - Country:US
Practice Address - Phone:801-662-1640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9855274-12052080P0205X
IL0361180392080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAI72196Medicare UPIN