Healthcare Provider Details

I. General information

NPI: 1467559443
Provider Name (Legal Business Name): DIRK ROSS DIEFENDORF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 S ELLSWORTH AVE SUITE 607
SAN MATEO CA
94401-3956
US

IV. Provider business mailing address

101 S ELLSWORTH AVE SUITE 607
SAN MATEO CA
94401-3956
US

V. Phone/Fax

Practice location:
  • Phone: 650-347-0157
  • Fax: 650-347-0566
Mailing address:
  • Phone: 650-347-0157
  • Fax: 650-347-0566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberG53558
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: