Provider Demographics
NPI:1780628529
Name:STEVEN DISTEFANO PA
Entity Type:Organization
Organization Name:STEVEN DISTEFANO PA
Other - Org Name:GATEWAY TO HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:DISTEFANO
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:561-736-9899
Mailing Address - Street 1:6749 LAS COLINAS ST
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-6566
Mailing Address - Country:US
Mailing Address - Phone:561-641-4727
Mailing Address - Fax:561-641-4455
Practice Address - Street 1:4895 WINDWARD PASSAGE DR
Practice Address - Street 2:ST. #3
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-7741
Practice Address - Country:US
Practice Address - Phone:561-736-9899
Practice Address - Fax:561-736-2483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA14688225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4375Medicare ID - Type UnspecifiedMEDICARE GROUP #