Provider Demographics
NPI:1447276712
Name:DIZADJI, DESIREE (MD)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:DIZADJI
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 1:3803 SPRING ST
Mailing Address - Street 2:SUITE 410
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53405-1660
Mailing Address - Country:US
Mailing Address - Phone:262-687-8260
Mailing Address - Fax:262-687-8729
Practice Address - Street 1:3803 SPRING ST
Practice Address - Street 2:SUITE 410
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53405-1660
Practice Address - Country:US
Practice Address - Phone:262-687-8260
Practice Address - Fax:262-687-8729
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46845207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIG58143Medicare UPIN