Healthcare Provider Details

I. General information

NPI: 1689678153
Provider Name (Legal Business Name): PAUL KHALED DIBBS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2005
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 CORPORATE BLVD
LAFAYETTE LA
70508-3850
US

IV. Provider business mailing address

PO BOX 51742
LAFAYETTE LA
70505-1742
US

V. Phone/Fax

Practice location:
  • Phone: 337-942-1151
  • Fax:
Mailing address:
  • Phone: 337-942-1151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number11220R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: