Provider Demographics
NPI:1023071826
Name:DISTEFANO, JUDY A (DO)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:A
Last Name:DISTEFANO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9423 E 95TH CT
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5805
Mailing Address - Country:US
Mailing Address - Phone:918-496-2400
Mailing Address - Fax:405-948-6507
Practice Address - Street 1:9423 E 95TH CT
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5805
Practice Address - Country:US
Practice Address - Phone:918-496-2400
Practice Address - Fax:918-496-2436
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2007-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2161207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00344932Medicare PIN
OKE09723Medicare UPIN