=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831507284
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR DIRESTA AND ASSOCIATES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2014
-----------------------------------------------------
Last Update Date | 07/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 37 1/2 FORRESTER ST PROFESSIONAL BUILDING
-----------------------------------------------------
City | NEWBURYPORT
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01950-1938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-465-2122
-----------------------------------------------------
Fax | 978-465-0450
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 37 1/2 FORRESTER ST PROFESSIONAL BUILDING
-----------------------------------------------------
City | NEWBURYPORT
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01950-1938
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 978-465-2122
-----------------------------------------------------
Fax | 978-465-0450
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. HOLLIE JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 978-465-2122
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0131X
-----------------------------------------------------
Taxonomy Name | Foot Surgery Podiatrist
-----------------------------------------------------
License Number | 1523
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------