Provider Demographics
NPI:1407968050
Name:DIBALA, RICHARD PAUL (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:PAUL
Last Name:DIBALA
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 1:16 JACOBS HILL RD
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06250-1650
Mailing Address - Country:US
Mailing Address - Phone:860-456-2863
Mailing Address - Fax:
Practice Address - Street 1:1022 STORRS RD
Practice Address - Street 2:
Practice Address - City:STORRS MANSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06268-2639
Practice Address - Country:US
Practice Address - Phone:860-429-9321
Practice Address - Fax:860-429-4775
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT022511207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001225119Medicaid
CT080001969OtherMEDICARE ID
CTD02671Medicare UPIN