Provider Demographics
NPI:1417187790
Name:KOIRALA, DIBAS (MD)
Entity Type:Individual
Prefix:
First Name:DIBAS
Middle Name:
Last Name:KOIRALA
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:PO BOX 14883
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27415-4883
Mailing Address - Country:US
Mailing Address - Phone:336-274-6515
Mailing Address - Fax:336-275-0812
Practice Address - Street 1:3800 ROBERT PORCHER WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-2557
Practice Address - Country:US
Practice Address - Phone:336-282-0376
Practice Address - Fax:336-282-0376
Is Sole Proprietor?:No
Enumeration Date:2009-07-21
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-01302207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC154NCOtherBCBS OF NC
NC5196035OtherCIGNA
NC5913191Medicaid
NC9378613OtherAETNA
NC154NCOtherBCBS OF NC
NC5913191Medicaid