Provider Demographics
NPI:1629578836
Name:DIZON, JONATHAN BALAGOT (OD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:BALAGOT
Last Name:DIZON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 KAREN AVE UNIT 3507
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-5308
Mailing Address - Country:US
Mailing Address - Phone:562-896-1798
Mailing Address - Fax:
Practice Address - Street 1:4160 S DURANGO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147
Practice Address - Country:US
Practice Address - Phone:702-732-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2019-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1006152W00000X
CA33887TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist