Healthcare Provider Details

I. General information

NPI: 1063646552
Provider Name (Legal Business Name): ANTHONY DISTEFANO, JR MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2009
Last Update Date: 05/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

562 LINCOLN ST
WORCESTER MA
01605-1916
US

IV. Provider business mailing address

562 LINCOLN ST
WORCESTER MA
01605-1916
US

V. Phone/Fax

Practice location:
  • Phone: 508-852-6028
  • Fax: 508-721-7821
Mailing address:
  • Phone: 508-852-6028
  • Fax: 508-721-7821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number21567
License Number StateMA

VIII. Authorized Official

Name: ANTHONY J DISTEFANO JR.
Title or Position: OWNER
Credential: M.D.
Phone: 508-852-6028