Provider Demographics
NPI:1760453724
Name:DISTEFANO, LEO JOSEPH III (MD)
Entity Type:Individual
Prefix:MR
First Name:LEO
Middle Name:JOSEPH
Last Name:DISTEFANO
Suffix:III
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 1:970 FARMINGTON AVENUE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107
Mailing Address - Country:US
Mailing Address - Phone:860-561-4300
Mailing Address - Fax:860-561-1635
Practice Address - Street 1:970 FARMINGTON AVENUE
Practice Address - Street 2:SUITE 201
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107
Practice Address - Country:US
Practice Address - Phone:860-561-4300
Practice Address - Fax:860-561-1635
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0336562080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT735010OtherCONNECTICARE
CT00133656100Medicaid
CT01003365CT01OtherANTHEM BCBS