Provider Demographics
NPI:1992189948
Name:DIDEBAN, BAHRAM (MD)
Entity Type:Individual
Prefix:DR
First Name:BAHRAM
Middle Name:
Last Name:DIDEBAN
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 1:1625 NW 19TH CIR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605-4093
Mailing Address - Country:US
Mailing Address - Phone:786-300-7808
Mailing Address - Fax:786-565-4941
Practice Address - Street 1:18741 HIGH SPRINGS MAIN ST
Practice Address - Street 2:
Practice Address - City:HIGH SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32643-0074
Practice Address - Country:US
Practice Address - Phone:786-300-7808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-18
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME136670207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100007200Medicaid