Provider Demographics
NPI:1285725010
Name:IZZO, KENNETH L (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:IZZO
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 1:1811 BETHLEHEM PIKE
Mailing Address - Street 2:SUITE 221
Mailing Address - City:FLOURTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19031
Mailing Address - Country:US
Mailing Address - Phone:215-233-1223
Mailing Address - Fax:215-233-1141
Practice Address - Street 1:1811 BETHLEHEM PIKE
Practice Address - Street 2:SUITE 221
Practice Address - City:FLOURTOWN
Practice Address - State:PA
Practice Address - Zip Code:19031
Practice Address - Country:US
Practice Address - Phone:215-233-1223
Practice Address - Fax:215-233-1141
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD0171012081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAIZ112248OtherBCBS PERSONAL CHOICE
PA01927385Medicaid
0060080000OtherBCBS KEYSTONE EAST
PA3503051OtherAETNA
B36884Medicare UPIN
0060080000OtherBCBS KEYSTONE EAST