Provider Demographics
NPI:1932723905
Name:IZZO, DOMINIC (DO)
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:IZZO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1035 CHARLEVOIX DR
Mailing Address - Street 2:
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837-2223
Mailing Address - Country:US
Mailing Address - Phone:517-627-2181
Mailing Address - Fax:
Practice Address - Street 1:1035 CHARLEVOIX DR STE 100
Practice Address - Street 2:
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-2223
Practice Address - Country:US
Practice Address - Phone:517-627-2181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101027018207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine