Healthcare Provider Details

I. General information

NPI: 1780754499
Provider Name (Legal Business Name): T DANIEL DIBBLE MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1123 N EVERGREEN RD
SPOKANE VALLEY WA
99216-1138
US

IV. Provider business mailing address

PO BOX 808
VERADALE WA
99037-0808
US

V. Phone/Fax

Practice location:
  • Phone: 509-363-3100
  • Fax: 509-363-0300
Mailing address:
  • Phone: 509-363-3100
  • Fax: 509-363-0300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberM-7950
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberMD00048246
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT60041936
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10003398
License Number StateWA
# 5
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberMD00042632
License Number StateWA

VIII. Authorized Official

Name: T DANIEL DIBBLE
Title or Position: PRESIDENT
Credential: MD
Phone: 509-363-3100