Healthcare Provider Details

I. General information

NPI: 1538227434
Provider Name (Legal Business Name): DONALD ALWOOD DIBBERN JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 SW 10TH AVE SUITE 1301
PORTLAND OR
97205-2732
US

IV. Provider business mailing address

511 SW 10TH AVE SUITE 1301
PORTLAND OR
97205-2732
US

V. Phone/Fax

Practice location:
  • Phone: 503-228-0155
  • Fax: 503-226-8342
Mailing address:
  • Phone: 503-228-0155
  • Fax: 503-226-8342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberMD22872
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: