Provider Demographics
NPI:1982299434
Name:DIBACCO, SARAH MARY
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:MARY
Last Name:DIBACCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 1005 BOX 11185
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AA
Mailing Address - Zip Code:34009-0112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:USNH/NMRTC GUANTANAMO BAY, CUBA
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AA
Practice Address - Zip Code:34009-0112
Practice Address - Country:US
Practice Address - Phone:757-548-2998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-06
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102207481171000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider