Provider Demographics
NPI:1467559443
Name:DIEFENDORF, DIRK ROSS (MD)
Entity Type:Individual
Prefix:DR
First Name:DIRK
Middle Name:ROSS
Last Name:DIEFENDORF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:101 S ELLSWORTH AVE
Mailing Address - Street 2:SUITE 607
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-3956
Mailing Address - Country:US
Mailing Address - Phone:650-347-0157
Mailing Address - Fax:650-347-0566
Practice Address - Street 1:101 S ELLSWORTH AVE
Practice Address - Street 2:SUITE 607
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-3956
Practice Address - Country:US
Practice Address - Phone:650-347-0157
Practice Address - Fax:650-347-0566
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG53558204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G535580Medicare ID - Type Unspecified
CAA93235Medicare UPIN