Provider Demographics
NPI:1649387770
Name:DISTELMAN, HOWARD LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:HOWARD
Middle Name:LEE
Last Name:DISTELMAN
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 1:515 BOSTON ST
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2960
Mailing Address - Country:US
Mailing Address - Phone:203-453-3100
Mailing Address - Fax:203-458-9456
Practice Address - Street 1:515 BOSTON ST
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-2960
Practice Address - Country:US
Practice Address - Phone:203-453-3100
Practice Address - Fax:203-458-9456
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT028769207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E10240Medicare UPIN
180000690Medicare ID - Type Unspecified