Provider Demographics
NPI:1356301774
Name:DIBBLE, WILLIAM J (DO)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:DIBBLE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 101 D/E
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066
Mailing Address - Country:US
Mailing Address - Phone:315-637-7878
Mailing Address - Fax:315-744-1907
Practice Address - Street 1:4000 MEDICAL CENTER DR.
Practice Address - Street 2:SUITE 101 D/E
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-6610
Practice Address - Country:US
Practice Address - Phone:315-637-7878
Practice Address - Fax:315-637-7870
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191174207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01411527Medicaid
NYJ400037406Medicare PIN
NYRA5294Medicare ID - Type Unspecified
NY01411527Medicaid