Healthcare Provider Details

I. General information

NPI: 1609865930
Provider Name (Legal Business Name): STEPHEN LEE DIBLASI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 12/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4315 MACCORKLE AVE SE
CHARLESTON WV
25304-2503
US

IV. Provider business mailing address

4315 MACCORKLE AVE SE
CHARLESTON WV
25304-2503
US

V. Phone/Fax

Practice location:
  • Phone: 304-926-8080
  • Fax: 304-926-8083
Mailing address:
  • Phone: 304-926-8080
  • Fax: 304-926-8083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number053388
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number1803
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: