MEDICARE: COLLIN DIEFFENBACH

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	225100000X	Physical Therapist	PT39551	FL

General Provider Information

NPI Number	:	1053029306
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLIN DIEFFENBACH

Provider Business Mailing Address
First Line	:	13519 CAPITOL DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33613-3105
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	14813 N DALE MABRY HWY STE 720
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33618-2027
Country	:	US
Telephone Number	:	813-964-5982
Fax Number	:

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

Provider Enumeration Date	:	11/07/2022
Last Update Date	:	11/07/2022

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Directions to “ COLLIN DIEFFENBACH ” Practice Location

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