Healthcare Provider Details

I. General information

NPI: 1316188048
Provider Name (Legal Business Name): MICHAEL JOSEPH DIBIASE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2009
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11549 LOS OSOS VALLEY RD STE 208
SAN LUIS OBISPO CA
93405-6458
US

IV. Provider business mailing address

11549 LOS OSOS VALLEY RD STE 208
SAN LUIS OBISPO CA
93405-6458
US

V. Phone/Fax

Practice location:
  • Phone: 805-548-8585
  • Fax: 805-548-8589
Mailing address:
  • Phone: 805-548-8585
  • Fax: 805-548-8589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA106846
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA106846
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: