=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154488922
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRACE T. DUQUE-DIZON, MD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 GREENSBORO RD
-----------------------------------------------------
City | EATONTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31024-6054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-621-0905
-----------------------------------------------------
Fax | 478-742-0854
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4207
-----------------------------------------------------
City | MACON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31208-4207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 478-621-0905
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER - PRESIDENT
-----------------------------------------------------
Name | GRACE T DUQUE DIZON
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 478-621-0905
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Anesthesiology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------