Provider Demographics
NPI:1639193998
Name:DIZON, RICARDO C (MD LTD)
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:C
Last Name:DIZON
Suffix:
Gender:M
Credentials:MD LTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 S CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IL
Mailing Address - Zip Code:60804-2546
Mailing Address - Country:US
Mailing Address - Phone:708-656-3666
Mailing Address - Fax:708-656-3612
Practice Address - Street 1:1907 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IL
Practice Address - Zip Code:60804-2546
Practice Address - Country:US
Practice Address - Phone:708-656-3666
Practice Address - Fax:708-656-3612
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036049486207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036049486Medicaid
IL036049486Medicaid
ILD12984Medicare UPIN