MEDICARE: JENNIFER L DISTASIO M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	207V00000X	Obstetrics & Gynecology Physician	2010019752	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396065447
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER L DISTASIO M.D.

Provider Business Mailing Address
First Line	:	2790 CLAY EDWARDS DR STE 1200
Second Line	:
City	:	NORTH KANSAS CITY
State	:	MO
Zip	:	64116-3253
Country	:	US
Telephone Number	:	816-468-7800
Fax Number	:	816-468-8531

Provider Business Practice Location Address
First Line	:	2790 CLAY EDWARDS DR STE 1200
Second Line	:
City	:	NORTH KANSAS CITY
State	:	MO
Zip	:	64116-3253
Country	:	US
Telephone Number	:	816-468-7800
Fax Number	:	816-468-8531

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2010
Last Update Date	:	10/19/2017

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Directions to “ JENNIFER L DISTASIO M.D.” Practice Location

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