Provider Demographics
NPI:1295529055
Name:DI STASO, FEDERICO (MD)
Entity type:Individual
Prefix:
First Name:FEDERICO
Middle Name:
Last Name:DI STASO
Suffix:
Gender:
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:MSC08-4640
Mailing Address - Street 2:1 UNIVERSITY OF NEW MEXICO
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:81731
Mailing Address - Country:US
Mailing Address - Phone:505-272-4814
Mailing Address - Fax:505-272-0240
Practice Address - Street 1:MSC08-4640
Practice Address - Street 2:1 UNIVERSITY OF NEW MEXICO
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:81731
Practice Address - Country:US
Practice Address - Phone:505-272-4814
Practice Address - Fax:505-272-0240
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-07
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program