MEDICARE: DR. ANTHONY JOHN DISTASIO II 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	207X00000X	Orthopaedic Surgery Physician	0101041449	VA
2	207XX0801X	Orthopaedic Trauma Physician	0101041449	VA

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	:	1831195353
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANTHONY JOHN DISTASIO II M.D.

Provider Business Mailing Address
First Line	:	600 GRESHAM DR STE 204
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23507-1904
Country	:	US
Telephone Number	:	757-388-5680
Fax Number	:	757-388-5681

Provider Business Practice Location Address
First Line	:	600 GRESHAM DR STE 204
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23507-1904
Country	:	US
Telephone Number	:	757-388-5680
Fax Number	:	757-388-5681

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

Provider Enumeration Date	:	06/21/2005
Last Update Date	:	09/16/2024

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