Provider Demographics
NPI:1093750408
Name:DIZON, ANGELO MIRANDA (PT)
Entity Type:Individual
Prefix:
First Name:ANGELO
Middle Name:MIRANDA
Last Name:DIZON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1714 MILWAUKEE AV
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025
Mailing Address - Country:US
Mailing Address - Phone:847-699-6810
Mailing Address - Fax:847-699-6545
Practice Address - Street 1:1714 MILWAUKEE AV
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025
Practice Address - Country:US
Practice Address - Phone:847-699-6810
Practice Address - Fax:847-699-6545
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK18412Medicare ID - Type Unspecified