Provider Demographics
NPI:1609807346
Name:DIZON, CONSUELOS S (MD)
Entity Type:Individual
Prefix:
First Name:CONSUELOS
Middle Name:S
Last Name:DIZON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:874 E WOODWARD AVE SPC 32
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-9244
Mailing Address - Country:US
Mailing Address - Phone:510-995-1653
Mailing Address - Fax:
Practice Address - Street 1:OAK VALLEY HOSPITAL
Practice Address - Street 2:350 SOUTH OAK AVE.
Practice Address - City:OAKDALE
Practice Address - State:CA
Practice Address - Zip Code:95361
Practice Address - Country:US
Practice Address - Phone:303-848-4192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA26445207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAD6459153OtherDEA