Healthcare Provider Details

I. General information

NPI: 1639163769
Provider Name (Legal Business Name): DIBYAJIBAN MAHAPATRA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2005
Last Update Date: 09/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 WHITESPORT DR SW SUITE - 7
HUNTSVILLE AL
35801-6486
US

IV. Provider business mailing address

185 WHITESPORT DR SW SUITE - 7
HUNTSVILLE AL
35801-6486
US

V. Phone/Fax

Practice location:
  • Phone: 256-883-6966
  • Fax: 256-883-6432
Mailing address:
  • Phone: 256-883-6966
  • Fax: 256-883-6432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number20939
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: