Provider Demographics
NPI:1699374744
Name:DIBOS, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DIBOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 CALLE MARIBEL
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-3120
Mailing Address - Country:US
Mailing Address - Phone:760-593-9357
Mailing Address - Fax:
Practice Address - Street 1:343 W FELICITA AVE STE 10
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-6515
Practice Address - Country:US
Practice Address - Phone:760-975-3729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASLD4553156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician