Provider Demographics
NPI:1528786118
Name:DIZON, MARK (CAMTC 89825)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:DIZON
Suffix:
Gender:M
Credentials:CAMTC 89825
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 PARKROSE AVE
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-4420
Mailing Address - Country:US
Mailing Address - Phone:415-350-8793
Mailing Address - Fax:
Practice Address - Street 1:441 VICTORY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-6312
Practice Address - Country:US
Practice Address - Phone:415-350-8793
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-19
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA89825225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist