MEDICARE: MR. MICHAEL JOSEPH DISTEFANO PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251X0800X	Orthopedic Physical Therapist	41475	CA
2	2251X0800X	Orthopedic Physical Therapist	012611	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Q88121	OTHER	NY	BCBS
2	ANC890	OTHER	NY	OXFORD

General Provider Information

NPI Number	:	1396732715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL JOSEPH DISTEFANO PT

Provider Business Mailing Address
First Line	:	4650 PALM AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92154-8404
Country	:	US
Telephone Number	:	619-662-5277
Fax Number	:

Provider Business Practice Location Address
First Line	:	4650 PALM AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92154-8404
Country	:	US
Telephone Number	:	619-662-5277
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	11/19/2015

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