MEDICARE: LEONIDES DIZON M.D.

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	207P00000X	Emergency Medicine Physician	4301032990	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1619992088
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEONIDES DIZON M.D.

Provider Business Mailing Address
First Line	:	75 REMIT DRIVE
Second Line	:	LOCKBOX 6895
City	:	CHICAGO
State	:	IL
Zip	:	60675-6895
Country	:	US
Telephone Number	:	866-916-5259
Fax Number	:	231-922-4030

Provider Business Practice Location Address
First Line	:	2463 S M 30
Second Line	:
City	:	WEST BRANCH
State	:	MI
Zip	:	48661-9312
Country	:	US
Telephone Number	:	989-345-3660
Fax Number	:

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

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	02/08/2008

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