# JOHN J DISTAZIO, D.P.M., P.C.

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1316123052
- **Authorized official:** JOHN J DISTAZIO D.P.M. (OWNER)
- **Authorized official phone:** (412) 461-1108

## Contact information

- **Practice address:** 495 E WATERFRONT DRIVE, SUITE 230, HOMESTEAD, PA 15120-1151
- **Practice address phone:** (412) 461-1108
- **Practice address fax:** (412) 461-5490
- **Mailing address:** 495 E WATERFRONT DRIVE, SUITE 230, HOMESTEAD, PA 15120-1151
- **Mailing address phone:** (412) 461-1108
- **Mailing address fax:** (412) 461-5490

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 213ES0103X | Foot & Ankle Surgery Podiatrist | SC002842L | PA | Yes |

## Other

- **Enumeration date:** 01/11/2008
- **Last updated:** 04/02/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 0010941370001 | — | PA |
| 01 | — | 1316123052 | MC GROUP NPI NUMBER | PA |
| 01 | — | 1366414088 | INDIVIDUAL NPI NUMBER | PA |
| 01 | — | 175132 | MEDICARE LEGACY NUMBER | PA |
| 01 | — | 175132XXX | MC GROUP PROVIDER NUMBER | PA |