Provider Demographics
NPI:1609295781
Name:DISTASIO, MARCELLO MICHAEL JR (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MARCELLO
Middle Name:MICHAEL
Last Name:DISTASIO
Suffix:JR
Gender:M
Credentials:MD, PHD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:75 FRANCIS ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-6110
Mailing Address - Country:US
Mailing Address - Phone:617-732-7510
Mailing Address - Fax:617-277-9015
Practice Address - Street 1:310 CEDAR ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3218
Practice Address - Country:US
Practice Address - Phone:203-785-3624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT64362207ZP0101X, 207ZN0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology