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Individual

JOHN DISTASIO

Active
Sole proprietor
No

Provider details

NPI number
Gender
Man
Credential
M.D.

Contact information

Practice address
4751 S CLEVELAND AVE, FORT MYERS, FL 33907
(239) 343-9888
(239) 343-9868
Mailing address
PO BOX 2147, FT MYERS, FL 33902-2147
(239) 343-9888
(239) 343-9868

Taxonomy

Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
ME57595
FL

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
063826900
FL
Enumeration date
07/28/2005
Last updated
03/25/2021
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