1366414088 NPI number — JOHN J DISTAZIO DPM

Table of content: JOHN J DISTAZIO DPM (NPI 1366414088)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366414088 NPI number — JOHN J DISTAZIO DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DISTAZIO
Provider First Name:
JOHN
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DISTAZIO
Provider Other First Name:
JOHN
Provider Other Middle Name:
J
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPM, PC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1366414088
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/20/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
495 WATERFRONT DR E
Provider Second Line Business Mailing Address:
SUITE 230
Provider Business Mailing Address City Name:
HOMESTEAD
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15120-1140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
412-461-1108
Provider Business Mailing Address Fax Number:
412-461-5490

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
495 WATERFRONT DR E
Provider Second Line Business Practice Location Address:
SUITE 230
Provider Business Practice Location Address City Name:
HOMESTEAD
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15120-1140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-461-1108
Provider Business Practice Location Address Fax Number:
412-461-5490
Provider Enumeration Date:
02/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  SC002842L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0004134486 . This is a "AETNA PIN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1156610001 . This is a "DMERC PROV NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 455619 . This is a "HIGHMARK GRP PROV NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0010941370001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1009921 . This is a "GATEWAY HMO NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1205011277 . This is a "DMERC NPI NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1316123052 . This is a "RR MEDICARE GROUP NPI" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 175132 . This is a "HIGHMARK INDIVIDUAL PROV#" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 175132XXX . This is a "MC GROUP PROV NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1316123052 . This is a "MC GROUP NPI NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 1710911912 . This is a "HIGHMARK GROUP NPI NUMBER" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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