Healthcare Provider Details

I. General information

NPI: 1780889360
Provider Name (Legal Business Name): VICTORIA BANEZ DIZON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 12/20/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10305 PROMENADE PKWY ELK GROVE
ELK GROVE CA
95757-9400
US

IV. Provider business mailing address

10305 PROMENADE PKWY ELK GROVE
ELK GROVE CA
95757-9400
US

V. Phone/Fax

Practice location:
  • Phone: 916-544-6600
  • Fax:
Mailing address:
  • Phone: 916-544-6600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberBP1-0022199
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA102576
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: