Provider Demographics
NPI:1659384295
Name:DIZON, DOMINIC T (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:T
Last Name:DIZON
Suffix:
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 1:7035 N MAPLE AVE STE 102B
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-8026
Mailing Address - Country:US
Mailing Address - Phone:559-299-2997
Mailing Address - Fax:
Practice Address - Street 1:7035 N MAPLE AVE STE 102B
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-8026
Practice Address - Country:US
Practice Address - Phone:559-299-2997
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62295207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A622950Medicaid
G66756Medicare UPIN
CA00A622950Medicaid