Provider Demographics
NPI:1851094486
Name:DIBONA, KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:DIBONA
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 1:801 MASSACHUSETTS AVE FL 6
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2605
Mailing Address - Country:US
Mailing Address - Phone:617-414-5951
Mailing Address - Fax:617-414-9251
Practice Address - Street 1:801 MASSACHUSETTS AVE FL 6
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2605
Practice Address - Country:US
Practice Address - Phone:617-414-5951
Practice Address - Fax:617-414-9251
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-23
Last Update Date:2023-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA390200000X
MA3014442207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program