Basic Information
| Provider Information | |||||||||
| NPI: | 1063663359 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIMALIBOT | ||||||||
| FirstName: | RICCA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | DIMALIBOT | ||||||||
| OtherFirstName: | RICCA | ||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 919 HIDDEN RDG | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750383813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4692822713 | ||||||||
| FaxNumber: | 4692820996 | ||||||||
| Practice Location | |||||||||
| Address1: | 2401 TERMINI ST | ||||||||
| Address2: | SUITE 100-D | ||||||||
| City: | DICKINSON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775394995 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7138031830 | ||||||||
| FaxNumber: | 2815343492 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2008 | ||||||||
| LastUpdateDate: | 01/02/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M9975 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | A98250 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 203519801 | 05 | TX | MEDICAID |