Provider Demographics
NPI:1932376167
Name:DIZON-MENEZES, DIANELLA V (MD)
Entity Type:Individual
Prefix:
First Name:DIANELLA
Middle Name:V
Last Name:DIZON-MENEZES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DIANELLA
Other - Middle Name:V
Other - Last Name:DIZON-MENEZES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 5800
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305
Mailing Address - Country:US
Mailing Address - Phone:708-488-4968
Mailing Address - Fax:708-366-1017
Practice Address - Street 1:8311 W ROOSEVELT RD
Practice Address - Street 2:ADVANCED PSYCHIATRIC SERVICES
Practice Address - City:FOREST PARK
Practice Address - State:IL
Practice Address - Zip Code:60130
Practice Address - Country:US
Practice Address - Phone:708-488-4968
Practice Address - Fax:708-366-1017
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360560612084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036056061Medicaid
IL036056061Medicaid
IL606531Medicare PIN