Provider Demographics
NPI:1700809670
Name:DIZON, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:DIZON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 629
Mailing Address - Street 2:
Mailing Address - City:CHRISTIANSTED
Mailing Address - State:VI
Mailing Address - Zip Code:00821-0629
Mailing Address - Country:US
Mailing Address - Phone:340-778-5780
Mailing Address - Fax:340-773-2753
Practice Address - Street 1:4500 SION FARM SUITE 3B
Practice Address - Street 2:
Practice Address - City:CHRISTIANSTED
Practice Address - State:VI
Practice Address - Zip Code:00820-4424
Practice Address - Country:US
Practice Address - Phone:340-778-5780
Practice Address - Fax:888-686-4557
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI1192207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
VI1192OtherLICENSE
VIH82805Medicare UPIN
VI1192OtherLICENSE