Provider Demographics
NPI:1912093634
Name:DEFFIBAUGH, JOHN IRVIN III (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:IRVIN
Last Name:DEFFIBAUGH
Suffix:III
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 OSTER STREET
Mailing Address - Street 2:
Mailing Address - City:OSTERBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16667
Mailing Address - Country:US
Mailing Address - Phone:814-276-3212
Mailing Address - Fax:814-276-9253
Practice Address - Street 1:126 OSTER STREET
Practice Address - Street 2:
Practice Address - City:OSTERBURG
Practice Address - State:PA
Practice Address - Zip Code:16667
Practice Address - Country:US
Practice Address - Phone:814-276-3212
Practice Address - Fax:814-276-9253
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC003223L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010623490003Medicaid
PAUO2231Medicare UPIN
PA0010623490003Medicaid