Basic Information
| Provider Information | |||||||||
| NPI: | 1184667057 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIFFENDALL | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3714 TUDOR ARMS AVE | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212112246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103660165 | ||||||||
| FaxNumber: | 3013523568 | ||||||||
| Practice Location | |||||||||
| Address1: | 3332 PAPER MILL RD | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211311419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106281510 | ||||||||
| FaxNumber: | 4106281511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 10/30/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | TA1372 | MD | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 403626300 | 05 | MD | MEDICAID | 1086642 | 01 | MD | MAMSI | OTHER | 67500005 | 01 | DC | BLUE CROSS CAREFIRST | OTHER |