Basic Information
| Provider Information | |||||||||
| NPI: | 1558397687 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIBO | ||||||||
| FirstName: | IMAD | ||||||||
| MiddleName: | AL-DEEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1324 LAKELAND HILLS BLVD | ||||||||
| Address2: | ATTN: MANAGED CARE DEPT | ||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338054543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636871100 | ||||||||
| FaxNumber: | 8636306528 | ||||||||
| Practice Location | |||||||||
| Address1: | 1324 LAKELAND HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338054543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636871321 | ||||||||
| FaxNumber: | 8636036534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 06/10/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | ME100106 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.