Organization
JOHN J DISTAZIO, D.P.M., P.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JOHN J DISTAZIO D.P.M. (OWNER)
(412) 461-1108
Entity
Organization
Contact information
Practice address
495 E WATERFRONT DRIVE, SUITE 230, HOMESTEAD, PA 15120-1151
(412) 461-1108
(412) 461-5490
Mailing address
495 E WATERFRONT DRIVE, SUITE 230, HOMESTEAD, PA 15120-1151
(412) 461-1108
(412) 461-5490
Taxonomy
Speciality
Code
Description
License number
State
213ES0103X
Foot & Ankle Surgery Podiatrist
Primary
SC002842L
PA
Other
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
Enumeration date
01/11/2008
Last updated
04/02/2008
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