Provider Demographics
NPI:1275190738
Name:DESTEFANO, JOSEPH ANTHONY III (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:ANTHONY
Last Name:DESTEFANO
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 277723
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7723
Mailing Address - Country:US
Mailing Address - Phone:864-560-4123
Mailing Address - Fax:864-560-4023
Practice Address - Street 1:840 W FLOYD BAKER BLVD
Practice Address - Street 2:
Practice Address - City:GAFFNEY
Practice Address - State:SC
Practice Address - Zip Code:29341-1845
Practice Address - Country:US
Practice Address - Phone:864-489-3300
Practice Address - Fax:864-488-3744
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC82516207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCH783J577OtherMEDICARE PIN
SC825165Medicaid
SCSCH7836067OtherMEDICARE PIN
SCSCH7836084OtherMEDICARE PIN