Provider Demographics
NPI:1427056761
Name:DIBONA, MARCELLO (MD)
Entity type:Individual
Prefix:MR
First Name:MARCELLO
Middle Name:
Last Name:DIBONA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1073 MACE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-4415
Mailing Address - Country:US
Mailing Address - Phone:718-655-3535
Mailing Address - Fax:718-655-3045
Practice Address - Street 1:1073 MACE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-4415
Practice Address - Country:US
Practice Address - Phone:718-655-3535
Practice Address - Fax:718-655-3045
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174113207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A60881Medicare UPIN
16E621Medicare ID - Type Unspecified