Provider Demographics
NPI:1942486758
Name:DIJON, ROMMEL BANTOG (DPT)
Entity Type:Individual
Prefix:
First Name:ROMMEL
Middle Name:BANTOG
Last Name:DIJON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:ROMMEL
Other - Middle Name:BANTOG
Other - Last Name:DIJON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPT
Mailing Address - Street 1:17401 LA BONITA WAY
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-9037
Mailing Address - Country:US
Mailing Address - Phone:562-484-4329
Mailing Address - Fax:
Practice Address - Street 1:23232 PERALTA DR
Practice Address - Street 2:113
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1443
Practice Address - Country:US
Practice Address - Phone:949-922-2776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-11
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT237522251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18659OtherMEDICARE GROUP PTAN