Provider Demographics
NPI:1548318645
Name:DIBYAJIBAN MAHAPATRA,M.D.,P.C.
Entity type:Organization
Organization Name:DIBYAJIBAN MAHAPATRA,M.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DIBYAJIBAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHAPATRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-883-6966
Mailing Address - Street 1:16025 MICHELLE DRIVE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35803
Mailing Address - Country:US
Mailing Address - Phone:256-883-6125
Mailing Address - Fax:256-883-6432
Practice Address - Street 1:185 WHITESPORTS DRIVE
Practice Address - Street 2:SUITE NO. 7
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801
Practice Address - Country:US
Practice Address - Phone:256-883-6966
Practice Address - Fax:256-883-6432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL20939207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529911790Medicaid
AL510G700276Medicare PIN