Provider Demographics
NPI:1639163769
Name:MAHAPATRA, DIBYAJIBAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DIBYAJIBAN
Middle Name:
Last Name:MAHAPATRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:185 WHITESPORT DR SW
Mailing Address - Street 2:SUITE - 7
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-6486
Mailing Address - Country:US
Mailing Address - Phone:256-883-6966
Mailing Address - Fax:256-883-6432
Practice Address - Street 1:185 WHITESPORT DR SW
Practice Address - Street 2:SUITE - 7
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-6486
Practice Address - Country:US
Practice Address - Phone:256-883-6966
Practice Address - Fax:256-883-6432
Is Sole Proprietor?:No
Enumeration Date:2005-09-05
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AL20939207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051507491Medicaid
AL051507491OtherBCBS OF ALABAMA
AL051507491Medicaid
AL051507491Medicare PIN