Provider Demographics
NPI:1588855225
Name:DEBORAH R. DISTEFANO M.D.P.C.
Entity Type:Organization
Organization Name:DEBORAH R. DISTEFANO M.D.P.C.
Other - Org Name:DISTEFANO EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:MESERVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-648-3937
Mailing Address - Street 1:1815 GUNBARREL RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-3130
Mailing Address - Country:US
Mailing Address - Phone:423-648-3937
Mailing Address - Fax:423-648-2043
Practice Address - Street 1:1815 GUNBARREL RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-3130
Practice Address - Country:US
Practice Address - Phone:423-648-3937
Practice Address - Fax:423-648-2043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD14067261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
D45618Medicare UPIN
W48523Medicare UPIN
TNC64630Medicare UPIN
TNB04605Medicare UPIN
TNU97444Medicare UPIN