Provider Demographics
NPI:1114961935
Name:DISTEFANO, VINCENT JAMES (MD)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:JAMES
Last Name:DISTEFANO
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:DEVON MNR STE 100
Mailing Address - Street 2:235 LANCASTER AVENUE
Mailing Address - City:DEVON
Mailing Address - State:PA
Mailing Address - Zip Code:19333-1560
Mailing Address - Country:US
Mailing Address - Phone:610-688-6767
Mailing Address - Fax:610-688-3224
Practice Address - Street 1:DEVON MNR STE 100
Practice Address - Street 2:235 LANCASTER AVENUE
Practice Address - City:DEVON
Practice Address - State:PA
Practice Address - Zip Code:19333-1560
Practice Address - Country:US
Practice Address - Phone:610-688-6767
Practice Address - Fax:610-688-3224
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD028996L207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DI030365Medicare ID - Type Unspecified
B33660Medicare UPIN