Provider Demographics
NPI:1548296221
Name:DIBBLE, COLLEEN M (MD)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:DIBBLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:M
Other - Last Name:CRUMLISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:624 MCCLELLAN ST
Mailing Address - Street 2:SUITE G02
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12304-1020
Mailing Address - Country:US
Mailing Address - Phone:518-382-2203
Mailing Address - Fax:518-382-2226
Practice Address - Street 1:624 MCCLELLAN ST
Practice Address - Street 2:SUITE G02
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12304-1020
Practice Address - Country:US
Practice Address - Phone:518-382-2203
Practice Address - Fax:518-382-2226
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY263695207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY755CJ1OtherEMPIRE BLUECROSS/BLUESHIELD
NY7367465OtherAETNA
NY130603000000OtherFIDELIS
NY03561199Medicaid
NY755CJ1OtherEMPIRE BLUECROSS/BLUESHIELD