Provider Demographics
NPI:1164884342
Name:DESTA, MUUZ
Entity Type:Individual
Prefix:
First Name:MUUZ
Middle Name:
Last Name:DESTA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5602 WHITCOMB CT APT B
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46224-6761
Mailing Address - Country:US
Mailing Address - Phone:404-542-3225
Mailing Address - Fax:
Practice Address - Street 1:5602 WHITCOMB CT APT B
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-6761
Practice Address - Country:US
Practice Address - Phone:404-542-3225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-25
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CODR.0067304207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program