Provider Demographics
NPI:1003810789
Name:DISTEFANO, LISA G (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:G
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12541 FOSTER ST STE 300
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66213-2304
Mailing Address - Country:US
Mailing Address - Phone:913-317-3200
Mailing Address - Fax:913-317-3218
Practice Address - Street 1:12541 FOSTER ST STE 300
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66213-2304
Practice Address - Country:US
Practice Address - Phone:913-317-3200
Practice Address - Fax:913-317-3218
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO119536207R00000X, 208000000X
KS0450138207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0520171Medicaid
MO204665202Medicaid
MOG72305Medicare UPIN
IA0520171Medicaid