Provider Demographics
NPI:1538131628
Name:DIZON, HERMES G (MD)
Entity Type:Individual
Prefix:
First Name:HERMES
Middle Name:G
Last Name:DIZON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:HERMES
Other - Middle Name:VILLA
Other - Last Name:GUERRERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:446 EFFINGHAM ST.
Mailing Address - Street 2:STE 302
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704
Mailing Address - Country:US
Mailing Address - Phone:757-673-6277
Mailing Address - Fax:757-673-6411
Practice Address - Street 1:446 EFFINGHAM ST.
Practice Address - Street 2:STE 302
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704
Practice Address - Country:US
Practice Address - Phone:757-673-6277
Practice Address - Fax:757-673-6411
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101048911208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010109230Medicaid