Provider Demographics
NPI:1669492575
Name:IRVIN & DIBRELL MEDICAL CLINIC, PA
Entity Type:Organization
Organization Name:IRVIN & DIBRELL MEDICAL CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:IRVIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-269-9800
Mailing Address - Street 1:P. O. BOX 106
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:AR
Mailing Address - Zip Code:72560
Mailing Address - Country:US
Mailing Address - Phone:870-269-9800
Mailing Address - Fax:870-269-9614
Practice Address - Street 1:803 WEST MAIN
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:AR
Practice Address - Zip Code:72560
Practice Address - Country:US
Practice Address - Phone:870-269-9800
Practice Address - Fax:870-269-9614
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARDB3125OtherRAILROAD MEDICARE
AR5C651OtherBLUE CROSS BLUE SHIELD
AR5C651OtherBLUE CROSS BLUE SHIELD
AR=========00OtherQUALCHOICE