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General NPI Number Information
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NPI Number | 1396732715
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Entity Type | Individual
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Provider Name | MICHAEL JOSEPH DISTEFANO PT
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Gender | Male
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Dates
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Enumeration Date | 09/30/2005
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Last Update Date | 11/19/2015
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Provider Practice Location Address
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Address Line | 4650 PALM AVE
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City | SAN DIEGO
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State | CA
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Zip | 92154-8404
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Country | US
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Telephone | 619-662-5277
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Fax |
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Provider Business Mailing Address
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Address Line | 4650 PALM AVE
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City | SAN DIEGO
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State | CA
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Zip | 92154-8404
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Country | US
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Telephone | 619-662-5277
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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 | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | 41475
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 2251X0800X
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Taxonomy Name | Orthopedic Physical Therapist
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License Number | 012611
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License Number State | NY
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