Provider Demographics
NPI:1134103716
Name:DIBACCO, ROBERT SALVATORE (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:SALVATORE
Last Name:DIBACCO
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 1:5053 S CONGRESS AVE
Mailing Address - Street 2:STE 204
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-4706
Mailing Address - Country:US
Mailing Address - Phone:561-969-7300
Mailing Address - Fax:561-969-6922
Practice Address - Street 1:5053 S CONGRESS AVE
Practice Address - Street 2:STE 204
Practice Address - City:ATLANTIS
Practice Address - State:FL
Practice Address - Zip Code:33461-4706
Practice Address - Country:US
Practice Address - Phone:561-969-7300
Practice Address - Fax:561-969-6922
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0038989207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL93992YOtherBCBS
FLME0038989OtherSTATE LICENSE
FL070012428OtherMEDICARE RAILROAD
FL93992Medicare ID - Type Unspecified
D63088Medicare UPIN