Provider Demographics
NPI:1932576972
Name:IZQUIERDO, ILDA (PT)
Entity type:Individual
Prefix:
First Name:ILDA
Middle Name:
Last Name:IZQUIERDO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11201 QUEENS BLVD APT 14D
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-5590
Mailing Address - Country:US
Mailing Address - Phone:718-544-9532
Mailing Address - Fax:
Practice Address - Street 1:405 43RD ST
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:NJ
Practice Address - Zip Code:07087-5047
Practice Address - Country:US
Practice Address - Phone:201-617-0880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00159600225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist