Provider Demographics
NPI:1033954383
Name:DISTERHAFT, PATRICK JAY JR (DO, MPH)
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:JAY
Last Name:DISTERHAFT
Suffix:JR
Gender:M
Credentials:DO, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18240 ASTOR DR APT 102
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-5635
Mailing Address - Country:US
Mailing Address - Phone:920-273-9301
Mailing Address - Fax:
Practice Address - Street 1:945 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-1305
Practice Address - Country:US
Practice Address - Phone:414-219-7136
Practice Address - Fax:414-219-6264
Is Sole Proprietor?:No
Enumeration Date:2024-06-27
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program