Provider Demographics
NPI:1407236185
Name:DIEFENDERFER, JOHN W (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:W
Last Name:DIEFENDERFER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-4974
Mailing Address - Country:US
Mailing Address - Phone:207-861-5101
Mailing Address - Fax:207-872-4341
Practice Address - Street 1:149 NORTH ST
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4974
Practice Address - Country:US
Practice Address - Phone:207-861-5101
Practice Address - Fax:207-872-4341
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-08
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO 4638207Q00000X
MEDO2785207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine