Provider Demographics
NPI:1700010410
Name:DISTASIO, SUSAN (DO)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:DISTASIO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8717 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-4546
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3713 E TREMONT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10465-2054
Practice Address - Country:US
Practice Address - Phone:718-792-4878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-08
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY2711092081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program