Individual
DOMINICK DISTASIO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
11 ROUTE 111, SMITHTOWN, NY 11787-3754
(631) 920-8028
Mailing address
5 HUDSON DR, KINGS PARK, NY 11754-4411
Taxonomy
Speciality
Code
Description
License number
State
171M00000X
Case Manager/Care Coordinator
Primary
—
—
Other
Enumeration date
04/14/2017
Last updated
04/14/2017
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