Basic Information
| Provider Information | |||||||||
| NPI: | 1609295781 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DISTASIO | ||||||||
| FirstName: | MARCELLO | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D., PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 FRANCIS ST | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021156110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6177327510 | ||||||||
| FaxNumber: | 6172779015 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 CEDAR ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065103218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037853624 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2014 | ||||||||
| LastUpdateDate: | 11/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0101X | 64362 | CT | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ZN0500X | 64362 | CT | Y | Allopathic & Osteopathic Physicians | Pathology | Neuropathology |
No ID Information.