Provider Demographics
NPI:1063646552
Name:ANTHONY DISTEFANO, JR MD
Entity Type:Organization
Organization Name:ANTHONY DISTEFANO, JR MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DISTEFANO
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:508-852-6028
Mailing Address - Street 1:562 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-1916
Mailing Address - Country:US
Mailing Address - Phone:508-852-6028
Mailing Address - Fax:508-721-7821
Practice Address - Street 1:562 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-1916
Practice Address - Country:US
Practice Address - Phone:508-852-6028
Practice Address - Fax:508-721-7821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-12
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21567207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM11882Medicare PIN