Provider Demographics
NPI:1326070871
Name:DIZON, ERNESTO G JR (MD)
Entity type:Individual
Prefix:
First Name:ERNESTO
Middle Name:G
Last Name:DIZON
Suffix:JR
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-0719
Mailing Address - Country:US
Mailing Address - Phone:509-837-1617
Mailing Address - Fax:
Practice Address - Street 1:500 S 11TH ST
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-2240
Practice Address - Country:US
Practice Address - Phone:509-837-7722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053848208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA159884778DMedicaid
GA159884778CMedicaid
GA159884778DMedicaid
GA511I020018Medicare PIN
P00617044Medicare PIN
GA02BDJFPMedicare PIN