Individual
MR. LEO JOSEPH DISTEFANO III
Active
Sole proprietor
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
970 FARMINGTON AVENUE, SUITE 201, WEST HARTFORD, CT 06107
(860) 561-4300
(860) 561-1635
Mailing address
970 FARMINGTON AVENUE, SUITE 201, WEST HARTFORD, CT 06107
(860) 561-4300
(860) 561-1635
Taxonomy
Speciality
Code
Description
License number
State
2080A0000X
Pediatric Adolescent Medicine Physician
Primary
033656
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00133656100
—
CT
01
—
01003365CT01
ANTHEM BCBS
CT
01
—
735010
CONNECTICARE
CT
Enumeration date
01/30/2006
Last updated
07/08/2007
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