Provider Demographics
NPI:1396998944
Name:IZQUIERDO, WILSON (MD)
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:IZQUIERDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:WILSON
Other - Middle Name:
Other - Last Name:IZQUIERDO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5810 SHERIDAN ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-3244
Mailing Address - Country:US
Mailing Address - Phone:954-251-2381
Mailing Address - Fax:954-251-2365
Practice Address - Street 1:5810 SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-3244
Practice Address - Country:US
Practice Address - Phone:954-251-2381
Practice Address - Fax:954-251-2365
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA117127207Q00000X
PR17291208D00000X
FLME112185207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice