MEDICARE: GUADALUPE E. DIZON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	119092	NY

General Provider Information

NPI Number	:	1134188618
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GUADALUPE E. DIZON MD

Provider Business Mailing Address
First Line	:	1413 FULTON ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11216-2607
Country	:	US
Telephone Number	:	718-636-4500
Fax Number	:	718-636-2998

Provider Business Practice Location Address
First Line	:	1413 FULTON ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11216-2607
Country	:	US
Telephone Number	:	718-636-4500
Fax Number	:	718-636-2998

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2006
Last Update Date	:	07/08/2007

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