Provider Demographics
NPI:1982776258
Name:DIZON-MOORE, RUTHEVA (MD)
Entity type:Individual
Prefix:
First Name:RUTHEVA
Middle Name:
Last Name:DIZON-MOORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERFOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305
Mailing Address - Country:US
Mailing Address - Phone:708-771-2950
Mailing Address - Fax:708-771-2950
Practice Address - Street 1:146 PARK AVE
Practice Address - Street 2:
Practice Address - City:RIVERFOREST
Practice Address - State:IL
Practice Address - Zip Code:60305
Practice Address - Country:US
Practice Address - Phone:708-771-2950
Practice Address - Fax:708-771-2950
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILY95120Medicare ID - Type Unspecified
C93129Medicare UPIN