Provider Demographics
NPI:1548774425
Name:DIFFENBAUGH, DEAN
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:
Last Name:DIFFENBAUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 SPOTSYLVANIA MALL STE 440A
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-1126
Mailing Address - Country:US
Mailing Address - Phone:540-786-2272
Mailing Address - Fax:
Practice Address - Street 1:137 SPOTSYLVANIA MALL STE 440A
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-1126
Practice Address - Country:US
Practice Address - Phone:540-786-2272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VATBD156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician