Provider Demographics
NPI:1669510954
Name:DIZON, JACINTO ANTONIO V (MD)
Entity Type:Individual
Prefix:DR
First Name:JACINTO
Middle Name:ANTONIO V
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 1:1211 S PRAIRIE AVE
Mailing Address - Street 2:SUITE 5505
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-3645
Mailing Address - Country:US
Mailing Address - Phone:847-212-9809
Mailing Address - Fax:
Practice Address - Street 1:1211 S PRAIRIE AVE
Practice Address - Street 2:SUITE 5505
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605
Practice Address - Country:US
Practice Address - Phone:847-212-9809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL360852192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36085219Medicaid
F68400Medicare UPIN