Provider Demographics
NPI:1558629113
Name:DIFFENDAFFER, DEREK C (MD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:C
Last Name:DIFFENDAFFER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4502 E 41ST ST.
Mailing Address - Street 2:SCHUSTERMAN CENTER
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2512
Mailing Address - Country:US
Mailing Address - Phone:918-660-3000
Mailing Address - Fax:
Practice Address - Street 1:7600 W TIDWELL RD STE 103
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77040-5719
Practice Address - Country:US
Practice Address - Phone:713-461-3573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-01
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR92062085R0202X
OK390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty