MEDICARE: MR. MARCELLO DIBONA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	174113	NY

General Provider Information

NPI Number	:	1427056761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARCELLO DIBONA MD

Provider Business Mailing Address
First Line	:	1073 MACE AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10469-4415
Country	:	US
Telephone Number	:	718-655-3535
Fax Number	:	718-655-3045

Provider Business Practice Location Address
First Line	:	1073 MACE AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10469-4415
Country	:	US
Telephone Number	:	718-655-3535
Fax Number	:	718-655-3045

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2005
Last Update Date	:	12/30/2009

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