Provider Demographics
NPI:1629578836
Name:DIZON, JONATHAN BALAGOT (OD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:BALAGOT
Last Name:DIZON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 GRACIE KILTZ LN APT 404
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-0089
Mailing Address - Country:US
Mailing Address - Phone:562-896-1798
Mailing Address - Fax:
Practice Address - Street 1:10000 RESEARCH BLVD STE 150
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-5814
Practice Address - Country:US
Practice Address - Phone:512-890-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1006152W00000X
CA33887TLG152W00000X
TX11105T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist