Healthcare Provider Details

I. General information

NPI: 1609172832
Provider Name (Legal Business Name): MICHAEL JAMES DISTLER DC, CCSP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2011
Last Update Date: 11/27/2024
Certification Date: 11/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 N HADDON AVE LOWR LEVEL
HADDONFIELD NJ
08033-2438
US

IV. Provider business mailing address

9 GREENVALE RD
MOORESTOWN NJ
08057-2234
US

V. Phone/Fax

Practice location:
  • Phone: 856-240-7529
  • Fax:
Mailing address:
  • Phone: 203-241-4574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number38MC00760100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code111NI0900X
TaxonomyInternist Chiropractor
License NumberN-A
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: