MEDICARE: DR. MICHAEL F DIFFENDALL OD

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	152W00000X	Optometrist	TA1372	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	1086642	OTHER	MD	MAMSI
3	67500005	OTHER	DC	BLUE CROSS CAREFIRST

General Provider Information

NPI Number	:	1184667057
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL F DIFFENDALL OD

Provider Business Mailing Address
First Line	:	3714 TUDOR ARMS AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21211-2246
Country	:	US
Telephone Number	:	410-366-0165
Fax Number	:	301-352-3568

Provider Business Practice Location Address
First Line	:	3332 PAPER MILL RD
Second Line	:
City	:	PHOENIX
State	:	MD
Zip	:	21131-1419
Country	:	US
Telephone Number	:	410-628-1510
Fax Number	:	410-628-1511

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

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	10/30/2013

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