Provider Demographics
NPI:1144421975
Name:DISTEFANO, ANDRA DAWN (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDRA
Middle Name:DAWN
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ANDRA
Other - Middle Name:DAWN
Other - Last Name:MARIOTTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1202 SOUTHVIEW RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21218-1400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:SUITE S11C07
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-9909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA103969207L00000X
PAMT188256207R00000X
MDD0070662207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine