Basic Information
| Provider Information | |||||||||
| NPI: | 1780606426 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIEFENDERFER | ||||||||
| FirstName: | KATHLYN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 PROFESSIONAL LN | ||||||||
| Address2: | |||||||||
| City: | ENTERPRISE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363302085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347938087 | ||||||||
| FaxNumber: | 3343930613 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 PROFESSIONAL LN | ||||||||
| Address2: | |||||||||
| City: | ENTERPRISE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363302085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343473404 | ||||||||
| FaxNumber: | 3343930613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 11/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 00023919 | AL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 009957070 | 05 | AL | MEDICAID | 51502734 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER |