Provider Demographics
NPI:1447328984
Name:DIZON, EMMANUEL PLENOS (MD)
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:PLENOS
Last Name:DIZON
Suffix:
Gender:M
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:HENRY FORD MEDICAL GROUP - DETROIT NORTHWEST
Mailing Address - Street 2:7800 W OUTER DRIVE
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235
Mailing Address - Country:US
Mailing Address - Phone:313-653-2300
Mailing Address - Fax:
Practice Address - Street 1:HENRY FORD MEDICAL GROUP - DETROIT NORTHWEST
Practice Address - Street 2:7800 W OUTER DRIVE
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235
Practice Address - Country:US
Practice Address - Phone:313-653-2300
Practice Address - Fax:313-653-2660
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301073823207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ED073823OtherCOMMERCIAL-COMMERCIAL NUMBER
ED073823OtherCHAMPUS-CHAMPUS
H72660Medicare UPIN