Provider Demographics
NPI:1740268812
Name:DIEFENBACH, WILLIAM
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:DIEFENBACH
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 1:2374 VILLAGE COMMON DR
Mailing Address - Street 2:STE 100
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-7201
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2374 VILLAGE COMMON DR
Practice Address - Street 2:STE 100
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-7201
Practice Address - Country:US
Practice Address - Phone:814-833-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD050177L207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001421230Medicaid
PA001421230Medicaid