Provider Demographics
NPI:1558487595
Name:DIFERDINANDO, CHERYL L (OD)
Entity Type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:L
Last Name:DIFERDINANDO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2659 S WOODLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-8601
Mailing Address - Country:US
Mailing Address - Phone:386-736-3579
Mailing Address - Fax:386-736-6447
Practice Address - Street 1:2659 S WOODLAND BLVD
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-8601
Practice Address - Country:US
Practice Address - Phone:386-736-3579
Practice Address - Fax:386-736-6447
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC001742152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL078632200Medicaid
FL078632200Medicaid
FLT84251Medicare UPIN