| NPI Details | |
|---|---|
| NPI | 1003810789 |
| Gender | Female |
| Enumeration Date | 06/09/2005 |
| Last Updated | 11/09/2012 |
| Entity Type | Individual |
| Active | Over 12 years ago |
| Practice Location | |
|---|---|
| 2016 S MAIN ST MARYVILLE MO, 64468-2655, US |
|
| Phone | (660) 562-2525 |
| Fax | (660) 562-7993 |
| Business Location | |
|---|---|
| 114 E SOUTH HILLS DR MARYVILLE MO, 64468-2659, US |
|
| Phone | (660) 562-2525 |
| Fax | (660) 562-4303 |
| Toxanomy | |
|---|---|
| Taxonomy Code | 208000000X |
| License State | Missouri |
| License Number | 119536 |
| Remove 1003810789 NPI Number | |
According to our database, Dr. Lisa G. Distefano M.D. NPI is 1003810789, taxonomy code is 208000000X and license number is 119536, license state is located at Missouri. Lisa G. Distefano M.D. physically located at 2016 S Main St, Maryville MO, 64468-2655. NPI Number Lisa G. Distefano M.D. has the Individual type.
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1003810789 NPI number is provided on an as is basis without warranty of any kind. 1003810789 is maintained by the National Plan & Provider Enumeration System. The contents of Lisa G. Distefano M.D. are for informational purposes only.
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