Provider Demographics
NPI:1831688159
Name:JOHN J DISTAZIO, D.P.M., P.C.
Entity type:Organization
Organization Name:JOHN J DISTAZIO, D.P.M., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEVLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-461-1108
Mailing Address - Street 1:495 E WATERFRONT DR STE 230
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:PA
Mailing Address - Zip Code:15120-1151
Mailing Address - Country:US
Mailing Address - Phone:412-461-1108
Mailing Address - Fax:
Practice Address - Street 1:640 RODI RD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15235-4512
Practice Address - Country:US
Practice Address - Phone:412-731-5500
Practice Address - Fax:412-731-5548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-02
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies