Individual
JOHN J DISTAZIO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DPM
Contact information
Practice address
495 WATERFRONT DR E, SUITE 230, HOMESTEAD, PA 15120-1140
(412) 461-1108
(412) 461-5490
Mailing address
495 WATERFRONT DR E, SUITE 230, HOMESTEAD, PA 15120-1140
(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
01
—
0004134486
AETNA PIN
PA
05
—
0010941370001
—
PA
01
—
1009921
GATEWAY HMO NUMBER
PA
01
—
1156610001
DMERC PROV NUMBER
PA
01
—
1205011277
DMERC NPI NUMBER
PA
01
—
1316123052
RR MEDICARE GROUP NPI
PA
01
—
1710911912
HIGHMARK GROUP NPI NUMBER
PA
01
—
175132
HIGHMARK INDIVIDUAL PROV#
PA
01
—
175132XXX
MC GROUP PROV NUMBER
PA
01
—
455619
HIGHMARK GRP PROV NUMBER
PA
Enumeration date
02/06/2006
Last updated
04/20/2010
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