Healthcare Provider Details

I. General information

NPI: 1942513882
Provider Name (Legal Business Name): JAMES GUIDO DISTEFANO JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2010
Last Update Date: 08/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

947 MARINA VILLAGE PKWY
ALAMEDA CA
94501-1048
US

IV. Provider business mailing address

947 MARINA VILLAGE PKWY
ALAMEDA CA
94501-1048
US

V. Phone/Fax

Practice location:
  • Phone: 510-522-6637
  • Fax:
Mailing address:
  • Phone: 510-522-6637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberA103423
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: