Provider Demographics
NPI:1689785495
Name:DIZON, RODERICK V (MD)
Entity Type:Individual
Prefix:DR
First Name:RODERICK
Middle Name:V
Last Name:DIZON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 23229
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42304-3229
Mailing Address - Country:US
Mailing Address - Phone:270-688-1330
Mailing Address - Fax:270-688-1338
Practice Address - Street 1:1301 PLEASANT VALLEY RD
Practice Address - Street 2:SUITE 500C
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-9774
Practice Address - Country:US
Practice Address - Phone:270-417-7830
Practice Address - Fax:270-417-7839
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010938642084N0400X
CAA965852084N0400X
WAMD607055512084N0400X
KYTP4332084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A965850Medicaid
CA00A965850Medicare PIN