Provider Demographics
NPI:1780754499
Name:T DANIEL DIBBLE MD PC
Entity type:Organization
Organization Name:T DANIEL DIBBLE MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:T
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:DIBBLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-363-3100
Mailing Address - Street 1:PO BOX 808
Mailing Address - Street 2:
Mailing Address - City:VERADALE
Mailing Address - State:WA
Mailing Address - Zip Code:99037-0808
Mailing Address - Country:US
Mailing Address - Phone:509-363-3100
Mailing Address - Fax:509-363-0300
Practice Address - Street 1:1123 N EVERGREEN RD
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1138
Practice Address - Country:US
Practice Address - Phone:509-363-3100
Practice Address - Fax:509-363-0300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-7950207LP2900X
WAMD000482462081P2900X
WAPT60041936225100000X
WAPA10003398363A00000X
WAMD00042632208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA217798OtherLABOR AND INDUSTRIES
ID805808900Medicaid
WA8802084Medicare ID - Type UnspecifiedNORIDIAN MEDICARE
WA217798OtherLABOR AND INDUSTRIES