Healthcare Provider Details

I. General information

NPI: 1366414088
Provider Name (Legal Business Name): JOHN J DISTAZIO DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOHN J DISTAZIO DPM, PC

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 04/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 WATERFRONT DR E SUITE 230
HOMESTEAD PA
15120-1140
US

IV. Provider business mailing address

495 WATERFRONT DR E SUITE 230
HOMESTEAD PA
15120-1140
US

V. Phone/Fax

Practice location:
  • Phone: 412-461-1108
  • Fax: 412-461-5490
Mailing address:
  • Phone: 412-461-1108
  • Fax: 412-461-5490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberSC002842L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: