Provider Demographics
NPI:1649567579
Name:DIPERNA, GARY (DO)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:DIPERNA
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 1:1600B CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2124
Mailing Address - Country:US
Mailing Address - Phone:207-774-5222
Mailing Address - Fax:207-761-4433
Practice Address - Street 1:1600B CONGRESS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2124
Practice Address - Country:US
Practice Address - Phone:207-774-5222
Practice Address - Fax:207-761-4433
Is Sole Proprietor?:No
Enumeration Date:2011-06-29
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDO2511207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E400317435Medicare PIN