Provider Demographics
NPI:1679577639
Name:DIBOS, LUIS A (MD)
Entity type:Individual
Prefix:DR
First Name:LUIS
Middle Name:A
Last Name:DIBOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3321 SUNSET KEY CIR UNIT 609
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33955-3906
Mailing Address - Country:US
Mailing Address - Phone:410-215-9666
Mailing Address - Fax:
Practice Address - Street 1:2380 HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-5024
Practice Address - Country:US
Practice Address - Phone:941-206-0325
Practice Address - Fax:941-766-0423
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN57068208G00000X
FLME128360208G00000X
WI66527208G00000X
CODR.0056660208G00000X
MDD40128208G00000X
SC51448208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD187171400Medicaid
MD187171400Medicaid
MD187171400Medicaid