Provider Demographics
NPI:1265004899
Name:DESTA, SELMAWIT
Entity Type:Individual
Prefix:
First Name:SELMAWIT
Middle Name:
Last Name:DESTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2471 BRITNEY LAKES LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32221-3817
Mailing Address - Country:US
Mailing Address - Phone:904-610-9305
Mailing Address - Fax:
Practice Address - Street 1:1100 CESERY BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-5674
Practice Address - Country:US
Practice Address - Phone:904-551-5884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4348492085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology