Healthcare Provider Details

I. General information

NPI: 1710016571
Provider Name (Legal Business Name): LYDIA DIZON JAZMINES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST SUITE 0019H
OAK LAWN IL
60453-2600
US

IV. Provider business mailing address

3555 VANILLA GRASS DR
NAPERVILLE IL
60564-8331
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-2529
  • Fax: 708-684-4446
Mailing address:
  • Phone: 708-684-2529
  • Fax: 708-684-4446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: