Provider Demographics
NPI:1942277157
Name:GATMAITAN DIZON, GERALDINE Y (MD)
Entity Type:Individual
Prefix:
First Name:GERALDINE
Middle Name:Y
Last Name:GATMAITAN DIZON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:GERALDINE
Other - Middle Name:
Other - Last Name:DIZON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:520 N 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-5257
Mailing Address - Country:US
Mailing Address - Phone:509-416-8849
Mailing Address - Fax:
Practice Address - Street 1:7425 WRIGLEY DR STE 101
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-5292
Practice Address - Country:US
Practice Address - Phone:509-546-8399
Practice Address - Fax:509-545-6842
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053816208000000X
WAMD60002198208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA207707713AMedicaid
GA207707713BMedicaid