Provider Demographics
NPI:1104828664
Name:DI STEFANO, ALFRED (MD)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:
Last Name:DI STEFANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 W RANDOL MILL RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76012-2510
Mailing Address - Country:US
Mailing Address - Phone:817-261-4906
Mailing Address - Fax:817-543-4675
Practice Address - Street 1:906 W RANDOL MILL RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76012-2510
Practice Address - Country:US
Practice Address - Phone:817-261-0929
Practice Address - Fax:817-265-7968
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE7891207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX100477204Medicaid
TX100477202Medicaid
TX100477205Medicaid
8B7830Medicare ID - Type UnspecifiedCMS
TX100477204Medicaid
TX8L23663Medicare PIN
TX100477205Medicaid
TX100477202Medicaid
TX8L23664Medicare PIN