Healthcare Provider Details

I. General information

NPI: 1003810789
Provider Name (Legal Business Name): LISA G. DISTEFANO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2005
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12541 FOSTER ST STE 300
OVERLAND PARK KS
66213-2304
US

IV. Provider business mailing address

12541 FOSTER ST STE 300
OVERLAND PARK KS
66213-2304
US

V. Phone/Fax

Practice location:
  • Phone: 913-317-3200
  • Fax: 913-317-3218
Mailing address:
  • Phone: 913-317-3200
  • Fax: 913-317-3218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number119536
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number119536
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0450138
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: