Provider Demographics
NPI:1366707069
Name:JAMES J DIRESTA DPM PLLC
Entity type:Organization
Organization Name:JAMES J DIRESTA DPM PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:J
Authorized Official - Last Name:DIRESTA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:978-465-2122
Mailing Address - Street 1:37 1/2 FORRESTER ST
Mailing Address - Street 2:
Mailing Address - City:NEWBURYPORT
Mailing Address - State:MA
Mailing Address - Zip Code:01950-1938
Mailing Address - Country:US
Mailing Address - Phone:978-465-2122
Mailing Address - Fax:
Practice Address - Street 1:37 1/2 FORRESTER ST
Practice Address - Street 2:
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-1938
Practice Address - Country:US
Practice Address - Phone:978-465-2122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-09
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA6722670001Medicare NSC
MA0027404Medicare PIN