Provider Demographics
NPI:1013357383
Name:DISTEFANO, JOSEPH (DPM)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:
Last Name:DISTEFANO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3225 SHALLOWFORD RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-1288
Mailing Address - Country:US
Mailing Address - Phone:770-999-0703
Mailing Address - Fax:770-999-0814
Practice Address - Street 1:3325 SHALLOWFORD RD STE 200
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062
Practice Address - Country:US
Practice Address - Phone:770-999-0804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01669213ES0103X
GAPOD001323213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003258042CMedicaid