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General NPI Number Information
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NPI Number | 1629578836
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Entity Type | Individual
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Provider Name | JONATHAN BALAGOT DIZON O.D.
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Gender | Male
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Dates
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Enumeration Date | 02/14/2018
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Last Update Date | 10/24/2024
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Provider Practice Location Address
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Address Line | 10000 RESEARCH BLVD STE 150
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City | AUSTIN
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State | TX
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Zip | 78759-5814
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Country | US
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Telephone | 512-890-2020
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Fax |
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Provider Business Mailing Address
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Address Line | 3000 GRACIE KILTZ LN APT 404
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City | AUSTIN
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State | TX
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Zip | 78758-0089
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Country | US
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Telephone | 562-896-1798
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1006
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License Number State | NV
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Taxonomy #2
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 33887TLG
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 11105T
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License Number State | TX
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