Provider Demographics
NPI:1225201221
Name:DISTEFANO, ROBERT (PT)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:DISTEFANO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 W 33RD ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3819
Mailing Address - Country:US
Mailing Address - Phone:405-330-3500
Mailing Address - Fax:
Practice Address - Street 1:1717 W 33RD ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3819
Practice Address - Country:US
Practice Address - Phone:405-330-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-10
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPT1535225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist