Provider Demographics
NPI:1538227434
Name:DIBBERN, DONALD ALWOOD JR (MD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:ALWOOD
Last Name:DIBBERN
Suffix:JR
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 1:511 SW 10TH AVE
Mailing Address - Street 2:SUITE 1301
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-2732
Mailing Address - Country:US
Mailing Address - Phone:503-228-0155
Mailing Address - Fax:503-226-8342
Practice Address - Street 1:511 SW 10TH AVE
Practice Address - Street 2:SUITE 1301
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2732
Practice Address - Country:US
Practice Address - Phone:503-228-0155
Practice Address - Fax:503-226-8342
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22872207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287494Medicaid
H43324Medicare UPIN
OR102183Medicare ID - Type UnspecifiedOR MEDICARE (GROUP)
OR287494Medicaid