Provider Demographics
NPI:1174612337
Name:DIFFENDAFFER, CLARK B (MD)
Entity type:Individual
Prefix:DR
First Name:CLARK
Middle Name:B
Last Name:DIFFENDAFFER
Suffix:
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 1:601 E ROLLINS ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-1248
Mailing Address - Country:US
Mailing Address - Phone:407-200-2355
Mailing Address - Fax:
Practice Address - Street 1:7601 PIONEERS BLVD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-4675
Practice Address - Country:US
Practice Address - Phone:402-484-6677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE243992085R0202X
FLTRN91012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology