Provider Demographics
NPI:1558397687
Name:DIBO, IMAD AL-DEEN (MD)
Entity Type:Individual
Prefix:
First Name:IMAD
Middle Name:AL-DEEN
Last Name:DIBO
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 1:1324 LAKELAND HILLS BLVD
Mailing Address - Street 2:ATTN: MANAGED CARE DEPT
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-4543
Mailing Address - Country:US
Mailing Address - Phone:863-687-1100
Mailing Address - Fax:863-630-6528
Practice Address - Street 1:1324 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-4543
Practice Address - Country:US
Practice Address - Phone:863-687-1321
Practice Address - Fax:863-603-6534
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100106207RI0200X, 207RI0200X
GA050707207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL280865000Medicaid
GA502583946AMedicaid
GA795006OtherBLUE CROSS
GAH73412Medicare UPIN
GA795006OtherBLUE CROSS
FL0471260001Medicare NSC
FL280865000Medicaid