MEDICARE: DR. DEREK C DIFFENDAFFER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	R9206	TX
2	390200000X	Student in an Organized Health Care Education/Training Program		OK

General Provider Information

NPI Number	:	1558629113
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEREK C DIFFENDAFFER M.D.

Provider Business Mailing Address
First Line	:	4502 E 41ST ST.
Second Line	:	SCHUSTERMAN CENTER
City	:	TULSA
State	:	OK
Zip	:	74135-2512
Country	:	US
Telephone Number	:	918-660-3000
Fax Number	:

Provider Business Practice Location Address
First Line	:	7600 W TIDWELL RD STE 103
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77040-5719
Country	:	US
Telephone Number	:	713-461-3573
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2012
Last Update Date	:	12/21/2018

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