Provider Demographics
NPI:1326070871
Name:DIZON, ERNESTO G JR (MD)
Entity Type:Individual
Prefix:
First Name:ERNESTO
Middle Name:G
Last Name:DIZON
Suffix:JR
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 1:7203 W DESCHUTES AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7777
Mailing Address - Country:US
Mailing Address - Phone:509-737-1880
Mailing Address - Fax:509-737-1879
Practice Address - Street 1:3730 PLAZA WAY FL 5
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99338-2718
Practice Address - Country:US
Practice Address - Phone:509-221-6550
Practice Address - Fax:509-221-6511
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053848208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA159884778DMedicaid
GA159884778CMedicaid
GA159884778DMedicaid
GA511I020018Medicare PIN
P00617044Medicare PIN
GA02BDJFPMedicare PIN