Basic Information
| Provider Information | |||||||||
| NPI: | 1285710830 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIBBLE | ||||||||
| FirstName: | CARLOS | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 N KEYS RD | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989011172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098655600 | ||||||||
| FaxNumber: | 5098655783 | ||||||||
| Practice Location | |||||||||
| Address1: | 510 W 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989481564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098655600 | ||||||||
| FaxNumber: | 5098655783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 06/16/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 10355 | UT | N | Other Service Providers | Specialist | 207V00000X | MD60639951 | WA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1508817313 | 05 | WA | MEDICAID | GAB01517 | 01 | WA | MEDICARE | OTHER |