Basic Information
| Provider Information | |||||||||
| NPI: | 1326070871 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIZON | ||||||||
| FirstName: | ERNESTO | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7203 W DESCHUTES AVE | ||||||||
| Address2: | |||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993367777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5097371880 | ||||||||
| FaxNumber: | 5097371879 | ||||||||
| Practice Location | |||||||||
| Address1: | 3730 PLAZA WAY FL 5 | ||||||||
| Address2: | |||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993382718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092216550 | ||||||||
| FaxNumber: | 5092216511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 02/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 053848 | GA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 159884778D | 05 | GA | MEDICAID | 159884778C | 05 | GA | MEDICAID |