Provider Demographics
NPI:1033616602
Name:DESTEFANO, SHERILYN M (MD)
Entity Type:Individual
Prefix:
First Name:SHERILYN
Middle Name:M
Last Name:DESTEFANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4411 SW VERMONT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-1020
Mailing Address - Country:US
Mailing Address - Phone:503-494-9992
Mailing Address - Fax:503-494-1967
Practice Address - Street 1:4411 SW VERMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-1020
Practice Address - Country:US
Practice Address - Phone:503-494-9992
Practice Address - Fax:503-494-1967
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD211958207Q00000X
UT11410728-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine