Provider Demographics
NPI:1366414088
Name:DISTAZIO, JOHN J (DPM)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:J
Last Name:DISTAZIO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:J
Other - Last Name:DISTAZIO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM, PC
Mailing Address - Street 1:495 WATERFRONT DR E
Mailing Address - Street 2:SUITE 230
Mailing Address - City:HOMESTEAD
Mailing Address - State:PA
Mailing Address - Zip Code:15120-1140
Mailing Address - Country:US
Mailing Address - Phone:412-461-1108
Mailing Address - Fax:412-461-5490
Practice Address - Street 1:495 WATERFRONT DR E
Practice Address - Street 2:SUITE 230
Practice Address - City:HOMESTEAD
Practice Address - State:PA
Practice Address - Zip Code:15120-1140
Practice Address - Country:US
Practice Address - Phone:412-461-1108
Practice Address - Fax:412-461-5490
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-06
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002842L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0004134486OtherAETNA PIN
PA1156610001OtherDMERC PROV NUMBER
PA455619OtherHIGHMARK GRP PROV NUMBER
PA0010941370001Medicaid
PA1009921OtherGATEWAY HMO NUMBER
PA1205011277OtherDMERC NPI NUMBER
PA1316123052OtherRR MEDICARE GROUP NPI
PA175132OtherHIGHMARK INDIVIDUAL PROV#
PA175132XXXOtherMC GROUP PROV NUMBER
PA1316123052OtherMC GROUP NPI NUMBER
PA1710911912OtherHIGHMARK GROUP NPI NUMBER
PA0010941370001Medicaid
PA455619OtherHIGHMARK GRP PROV NUMBER