Provider Demographics
NPI:1477736270
Name:MICHAEL DISTEFANO, M.D., P.A.
Entity Type:Organization
Organization Name:MICHAEL DISTEFANO, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:DISTEFANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-261-5501
Mailing Address - Street 1:140 N RTE 17
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-2809
Mailing Address - Country:US
Mailing Address - Phone:201-261-5501
Mailing Address - Fax:201-261-3350
Practice Address - Street 1:140 N RTE 17
Practice Address - Street 2:SUITE 255
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-2809
Practice Address - Country:US
Practice Address - Phone:201-261-5501
Practice Address - Fax:201-261-3350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ096214Medicare PIN