Provider Demographics
NPI:1568430361
Name:DISTEFANO, ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:
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 1:116 E CENTER ST
Mailing Address - Street 2:SUITE 19
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-5215
Mailing Address - Country:US
Mailing Address - Phone:860-643-2731
Mailing Address - Fax:860-643-6707
Practice Address - Street 1:116 E CENTER ST
Practice Address - Street 2:SUITE 19
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-5215
Practice Address - Country:US
Practice Address - Phone:860-643-2731
Practice Address - Fax:860-643-6707
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT032190208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTF36839Medicare UPIN