Provider Demographics
NPI:1447498654
Name:DIZON, GLENN MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:GLENN
Middle Name:MICHAEL
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 1:6 GERMANTOWN RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-5027
Mailing Address - Country:US
Mailing Address - Phone:203-798-0522
Mailing Address - Fax:203-743-5634
Practice Address - Street 1:73 SAND PIT RD
Practice Address - Street 2:DANBURY SURGICAL CENTER
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-4042
Practice Address - Country:US
Practice Address - Phone:203-743-2400
Practice Address - Fax:203-743-2405
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-26
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT48909207L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program