Basic Information
| Provider Information | |||||||||
| NPI: | 1669426664 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIZLIK | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | D. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 908 COTTONWOOD CT | ||||||||
| Address2: | |||||||||
| City: | EASTLAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440955410 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 18901 LAKE SHORE BLVD | ||||||||
| Address2: | |||||||||
| City: | EUCLID | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441191078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165319000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 06/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 35.067445 | OH | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 942460636421 | 01 | OH | CARESOURCE | OTHER | 0263156 | 05 | OH | MEDICAID | P00321150 | 01 | OH | MEDICARE TRAVELERS RR-GA | OTHER |