Provider Demographics
NPI:1093897779
Name:DIFFENDERFER, FRED E (DC)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:E
Last Name:DIFFENDERFER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 LANCASTER PIKE
Mailing Address - Street 2:
Mailing Address - City:CIRCLEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43113-9272
Mailing Address - Country:US
Mailing Address - Phone:740-477-3333
Mailing Address - Fax:740-477-1100
Practice Address - Street 1:420 LANCASTER PIKE
Practice Address - Street 2:
Practice Address - City:CIRCLEVILLE
Practice Address - State:OH
Practice Address - Zip Code:43113-9272
Practice Address - Country:US
Practice Address - Phone:740-477-3333
Practice Address - Fax:740-477-1100
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1077111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0656875Medicaid
OH0656875Medicaid