Provider Demographics
NPI:1023017332
Name:DIZON, LOUIS (MD)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:
Last Name:DIZON
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 1:301 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-3804
Mailing Address - Country:US
Mailing Address - Phone:212-598-6351
Mailing Address - Fax:212-517-2137
Practice Address - Street 1:301 E 17TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3804
Practice Address - Country:US
Practice Address - Phone:212-598-6351
Practice Address - Fax:212-517-2137
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY284417208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNTN01KAOtherJOHN DEERE TENNCARE
VA1023017332Medicaid
VA017067B12Medicare PIN