Healthcare Provider Details

I. General information

NPI: 1487185765
Provider Name (Legal Business Name): JENNIFER DIBIAGIO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 07/31/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 N CHARLES ST STE 309
BALTIMORE MD
21204-5804
US

IV. Provider business mailing address

508 APPLEWOOD DR
BEL AIR MD
21014-2102
US

V. Phone/Fax

Practice location:
  • Phone: 443-849-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD89354
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: