Provider Demographics
NPI:1275536906
Name:DIBACCO, JOHN M (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:DIBACCO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 GORMAN AVE
Mailing Address - Street 2:STE 103
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-3154
Mailing Address - Country:US
Mailing Address - Phone:304-636-1548
Mailing Address - Fax:304-636-1566
Practice Address - Street 1:911 GORMAN AVE
Practice Address - Street 2:STE 103
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-3154
Practice Address - Country:US
Practice Address - Phone:304-636-1548
Practice Address - Fax:304-636-1566
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001857174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0150180000Medicaid