Basic Information
| Provider Information | |||||||||
| NPI: | 1285612077 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | DISTANT | ||||||||
| FirstName: | DALE | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 CLARKSON AVE | ||||||||
| Address2: | BOX 1262 | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112032056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182708867 | ||||||||
| FaxNumber: | 7182701794 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 CLARKSON AVE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112032056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182701422 | ||||||||
| FaxNumber: | 7182702826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 190405-1 | NY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01438926 | 05 | NY | MEDICAID |