Provider Demographics
NPI:1851389373
Name:DISTEFANO, TONY (DPM)
Entity Type:Individual
Prefix:DR
First Name:TONY
Middle Name:
Last Name:DISTEFANO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 STELTON ROAD
Mailing Address - Street 2:
Mailing Address - City:PISCATAWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08854-3244
Mailing Address - Country:US
Mailing Address - Phone:732-968-9494
Mailing Address - Fax:732-968-4703
Practice Address - Street 1:95 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-6092
Practice Address - Country:US
Practice Address - Phone:908-273-4300
Practice Address - Fax:973-285-7618
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD002584213E00000X
NJ25MD00258400213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU85634Medicare UPIN
NJ048989BSDMedicare ID - Type UnspecifiedMEDICARE#
NJ048989BDQMedicare PIN