Provider Demographics
NPI:1487614301
Name:DIBALA, ANNE C (MD)
Entity type:Individual
Prefix:DR
First Name:ANNE
Middle Name:C
Last Name:DIBALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 S FLANNAGAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266
Mailing Address - Country:US
Mailing Address - Phone:276-883-8042
Mailing Address - Fax:276-883-8044
Practice Address - Street 1:71 S FLANNAGAN AVENUE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266
Practice Address - Country:US
Practice Address - Phone:276-883-8042
Practice Address - Fax:276-883-8044
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC132142084P0800X
VA01010474982084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC405127Medicaid
VA534147000OtherMAGELLAN
SC132145Medicaid
VA1487614301Medicaid
SC327877Medicaid
VAP01414635OtherRAILROAD MEDICARE
SC3344Medicare UPIN
VA1487614301Medicaid
SCC81451Medicare UPIN
SC327877Medicaid
SC405127Medicaid