Basic Information
| Provider Information | |||||||||
| NPI: | 1487795225 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DISTEFANO | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | CRAIG | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1185 PARK AVE APT 1L | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 101281307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2124276101 | ||||||||
| FaxNumber: | 2124276128 | ||||||||
| Practice Location | |||||||||
| Address1: | 1190 5TH AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100296503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2124271540 | ||||||||
| FaxNumber: | 2124107196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 127858 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 00349606 | 05 | NY | MEDICAID |