Healthcare Provider Details

I. General information

NPI: 1629578836
Provider Name (Legal Business Name): JONATHAN BALAGOT DIZON O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2018
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44139 MONTEREY AVE STE A
PALM DESERT CA
92260-8700
US

IV. Provider business mailing address

3000 GRACIE KILTZ LN APT 404
AUSTIN TX
78758-0089
US

V. Phone/Fax

Practice location:
  • Phone: 760-469-5195
  • Fax: 760-779-0801
Mailing address:
  • Phone: 562-896-1798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1006
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number33887TLG
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number11105T
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: