Provider Demographics
NPI:1780676528
Name:DISTEFANO, MARY ANN (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARY ANN
Middle Name:
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:WAPPINGERS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12590-2424
Mailing Address - Country:US
Mailing Address - Phone:845-297-4110
Mailing Address - Fax:845-298-7099
Practice Address - Street 1:3 SPRING ST
Practice Address - Street 2:
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590-2424
Practice Address - Country:US
Practice Address - Phone:845-297-4110
Practice Address - Fax:845-298-7099
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY50692251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ3W9C1Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
NYQ57381Medicare ID - Type UnspecifiedMEDICARE CORPORATION NUMB