Healthcare Provider Details

I. General information

NPI: 1528029899
Provider Name (Legal Business Name): ALI A DIBA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 S 16TH ST 2015
MILWAUKEE WI
53215-4537
US

IV. Provider business mailing address

3033 S 27TH ST SUITE 202
MILWAUKEE WI
53215-3600
US

V. Phone/Fax

Practice location:
  • Phone: 414-908-6500
  • Fax: 414-385-2980
Mailing address:
  • Phone: 414-908-6601
  • Fax: 414-385-2980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number20383-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: