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General NPI Number Information
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NPI Number | 1225537525
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Entity Type | Individual
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Provider Name | DOUGLAS LOGAN DISTEFANO DPT
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Gender | Male
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Dates
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Enumeration Date | 02/02/2018
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 100 CALELLA RD STE 100
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City | HOT SPRINGS VILLAGE
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State | AR
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Zip | 71909-3174
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Country | US
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Telephone | 501-984-2453
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Fax | 501-525-1773
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Provider Business Mailing Address
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Address Line | 400 BAYSHORE DR APT B
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City | HOT SPRINGS
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State | AR
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Zip | 71901-9630
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Country | US
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Telephone | 318-792-7987
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 1300819
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License Number State | TX
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