Healthcare Provider Details

I. General information

NPI: 1902957665
Provider Name (Legal Business Name): JASON CHRISTIAN DIFUSCO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2451 FILLINGIM STREET, MSTN 611 HOUSESTAFF OFFICE
MOBILE AL
36617
US

IV. Provider business mailing address

2580 PATHWAY PL APT. B
MOBILE AL
36606-2324
US

V. Phone/Fax

Practice location:
  • Phone: 251-471-7000
  • Fax:
Mailing address:
  • Phone: 832-392-0527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: