Provider Demographics
NPI:1679605950
Name:VINCENT DISTEFANO, MD PC
Entity Type:Organization
Organization Name:VINCENT DISTEFANO, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:DISTEFANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-687-1400
Mailing Address - Street 1:860 W. LANCASTER AVENUE
Mailing Address - Street 2:
Mailing Address - City:DEVON
Mailing Address - State:PA
Mailing Address - Zip Code:19333-1316
Mailing Address - Country:US
Mailing Address - Phone:610-687-1400
Mailing Address - Fax:610-687-1065
Practice Address - Street 1:860 W. LANCASTER AVENUE
Practice Address - Street 2:
Practice Address - City:DEVON
Practice Address - State:PA
Practice Address - Zip Code:19333-1316
Practice Address - Country:US
Practice Address - Phone:610-687-1400
Practice Address - Fax:610-687-1065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD028996L207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB33660Medicare UPIN
PADI030365Medicare ID - Type Unspecified