Provider Demographics
NPI:1750738365
Name:DIBIANCO, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DIBIANCO
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 1:200 RETREAT AVE
Mailing Address - Street 2:HARTFORD HOSPITAL PSYCH DEPT
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-3309
Mailing Address - Country:US
Mailing Address - Phone:860-972-7909
Mailing Address - Fax:
Practice Address - Street 1:200 RETREAT AVE
Practice Address - Street 2:HARTFORD HOSPITAL PSYCH DEPT
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3309
Practice Address - Country:US
Practice Address - Phone:860-972-7909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT619672084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program