Provider Demographics
NPI:1265436604
Name:HIBBS, DIANE (DO)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:
Last Name:HIBBS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2702 N. 3RD ST.
Mailing Address - Street 2:STE. 4020
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1130
Mailing Address - Country:US
Mailing Address - Phone:602-323-3242
Mailing Address - Fax:602-323-3496
Practice Address - Street 1:635 E. BASELINE RD.
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042
Practice Address - Country:US
Practice Address - Phone:602-243-7277
Practice Address - Fax:602-243-1235
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2009-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3356207V00000X
AZ4746207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ325004Medicaid
OK90110053OtherPACIFIC CARE
OK100137780AMedicaid
OK243326007OtherMEDICARE
G90752Medicare UPIN
AZZ122544Medicare PIN
AZG90752Medicare UPIN
OK90110053OtherPACIFIC CARE