Healthcare Provider Details

I. General information

NPI: 1083173082
Provider Name (Legal Business Name): DAVID ANTHONY DISTEFANO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 08/16/2025
Certification Date: 08/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5719 WIDEWATERS PKWY
SYRACUSE NY
13214-1985
US

IV. Provider business mailing address

PO BOX 580
SYRACUSE NY
13214-0580
US

V. Phone/Fax

Practice location:
  • Phone: 315-251-3100
  • Fax: 315-449-9923
Mailing address:
  • Phone: 315-251-3140
  • Fax: 315-552-6046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number338689
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: