Basic Information
| Provider Information | |||||||||
| NPI: | 1760436893 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIBERT | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | WESLEY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 815 COX RD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280543453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048651700 | ||||||||
| FaxNumber: | 7048657948 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 COX RD | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280543453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048651700 | ||||||||
| FaxNumber: | 7048657948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2006 | ||||||||
| LastUpdateDate: | 07/09/2014 | ||||||||
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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 | 2084N0400X | 34595 | NC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2085N0700X | 34595 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology |
ID Information
| ID | Type | State | Issuer | Description | N34595 | 05 | SC | MEDICAID | 28459 | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER |