Provider Demographics
NPI:1942513882
Name:DISTEFANO, JAMES GUIDO JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:GUIDO
Last Name:DISTEFANO
Suffix:JR
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 1:947 MARINA VILLAGE PKWY
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-1048
Mailing Address - Country:US
Mailing Address - Phone:510-522-6637
Mailing Address - Fax:
Practice Address - Street 1:947 MARINA VILLAGE PKWY
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-1048
Practice Address - Country:US
Practice Address - Phone:510-522-6637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-21
Last Update Date:2013-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA103423207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1427081165Medicaid