Healthcare Provider Details

I. General information

NPI: 1639394372
Provider Name (Legal Business Name): MANUEL J DIZON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 WESTWOOD PL
LOS ANGELES CA
90025
US

IV. Provider business mailing address

221 WESTWOOD PL
LOS ANGELES CA
90025
US

V. Phone/Fax

Practice location:
  • Phone: 310-206-7725
  • Fax: 310-267-1996
Mailing address:
  • Phone: 310-206-7725
  • Fax: 310-267-1996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A7766
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDOS645
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: