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General NPI Number Information
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NPI Number | 1407968050
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Entity Type | Individual
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Provider Name | RICHARD PAUL DIBALA M.D.
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Gender | Male
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 05/29/2008
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Provider Practice Location Address
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Address Line | 1022 STORRS RD
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City | STORRS MANSFIELD
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State | CT
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Zip | 06268-2639
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Country | US
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Telephone | 860-429-9321
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Fax | 860-429-4775
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Provider Business Mailing Address
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Address Line | 16 JACOBS HILL RD
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City | MANSFIELD CENTER
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State | CT
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Zip | 06250-1650
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Country | US
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Telephone | 860-456-2863
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 022511
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License Number State | CT
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