Provider Demographics
NPI:1598768830
Name:DISTEFANO, THOMAS VINCENT (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:VINCENT
Last Name:DISTEFANO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 S AVENUE A
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-7127
Mailing Address - Country:US
Mailing Address - Phone:928-344-2000
Mailing Address - Fax:
Practice Address - Street 1:2460 S PARKVIEW LOOP STE 3
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-5357
Practice Address - Country:US
Practice Address - Phone:928-336-7846
Practice Address - Fax:928-336-7256
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO119582207X00000X
SC51607207X00000X
AZ75667207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC516070Medicaid
SC516070Medicaid
MOH02167Medicare UPIN
MD204664908Medicaid