Provider Demographics
NPI:1184667057
Name:DIFFENDALL, MICHAEL F (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:F
Last Name:DIFFENDALL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3714 TUDOR ARMS AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-2246
Mailing Address - Country:US
Mailing Address - Phone:410-366-0165
Mailing Address - Fax:301-352-3568
Practice Address - Street 1:3332 PAPER MILL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:MD
Practice Address - Zip Code:21131-1419
Practice Address - Country:US
Practice Address - Phone:410-628-1510
Practice Address - Fax:410-628-1511
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1372152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD403626300Medicaid
MD1086642OtherMAMSI
DC67500005OtherBLUE CROSS CAREFIRST
U60706Medicare UPIN
MD403626300Medicaid