Provider Demographics
NPI:1720211196
Name:MCCAFFERTY, DIEDRA ELENA AMENDOLA (DO)
Entity Type:Individual
Prefix:DR
First Name:DIEDRA
Middle Name:ELENA AMENDOLA
Last Name:MCCAFFERTY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:432 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-4004
Mailing Address - Country:US
Mailing Address - Phone:215-925-2400
Mailing Address - Fax:215-925-9162
Practice Address - Street 1:800 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-4717
Practice Address - Country:US
Practice Address - Phone:215-339-5100
Practice Address - Fax:215-454-6814
Is Sole Proprietor?:No
Enumeration Date:2009-09-01
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLUO 2270207Q00000X
PAOS016486207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine