Healthcare Provider Details

I. General information

NPI: 1669550422
Provider Name (Legal Business Name): PAUL E. DYBBRO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 06/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 MERCED ST
SAN LEANDRO CA
94577-4201
US

IV. Provider business mailing address

2500 MERCED ST
SAN LEANDRO CA
94577-4201
US

V. Phone/Fax

Practice location:
  • Phone: 510-454-4715
  • Fax:
Mailing address:
  • Phone: 510-454-7527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberG47684
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: