Provider Demographics
NPI:1346291754
Name:DESTEFANO, WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:DESTEFANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3081 AVENUE U
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-5116
Mailing Address - Country:US
Mailing Address - Phone:718-648-0969
Mailing Address - Fax:718-648-2624
Practice Address - Street 1:3081 AVENUE U
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-5116
Practice Address - Country:US
Practice Address - Phone:718-648-0969
Practice Address - Fax:718-648-2624
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163360207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0015618OtherGHI
NY00912134Medicaid
NYWD049D7110OtherEMPIRE BLUE CROSS BLUE SHIELD
NY0015618OtherGHI
NY00912134Medicaid