Provider Demographics
NPI:1154839561
Name:KENNETH P DIZON D.O INC
Entity Type:Organization
Organization Name:KENNETH P DIZON D.O INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:P
Authorized Official - Last Name:DIZON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:760-256-1004
Mailing Address - Street 1:930 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-2654
Mailing Address - Country:US
Mailing Address - Phone:760-256-1004
Mailing Address - Fax:760-256-1055
Practice Address - Street 1:930 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-2654
Practice Address - Country:US
Practice Address - Phone:760-256-1004
Practice Address - Fax:760-256-1055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-19
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A15716207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA930OtherPERSONAL