Healthcare Provider Details

I. General information

NPI: 1023284080
Provider Name (Legal Business Name): BASEMA ISMAIL DIBAS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2008
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-3887
  • Fax:
Mailing address:
  • Phone: 505-272-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-144300
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License NumberMD470610
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number036-144300
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number2010-02054
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number2007022719
License Number StateMO
# 6
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License NumberMD2022-1462
License Number StateNM
# 7
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2022-1462
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: