Healthcare Provider Details

I. General information

NPI: 1043268394
Provider Name (Legal Business Name): JAMES DONALD DIBDIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 12/21/2022
Certification Date: 12/21/2022
Deactivation Date: 05/23/2022
Reactivation Date: 08/26/2022

III. Provider practice location address

505 COAST BLVD SOUTH # 408
LA JOLLA CA
92037-4613
US

IV. Provider business mailing address

1223 WILSHIRE BLVD #234
SANTA MONICA CA
90403
US

V. Phone/Fax

Practice location:
  • Phone: 858-459-7788
  • Fax:
Mailing address:
  • Phone: 310-593-3945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA39483
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberA39483
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License NumberA39483
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: