Provider Demographics
NPI:1346326246
Name:DESTA, TADDESE TEFERI (MD)
Entity Type:Individual
Prefix:
First Name:TADDESE
Middle Name:TEFERI
Last Name:DESTA
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 1:292 EUCLID AVE STE 115
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114-3629
Mailing Address - Country:US
Mailing Address - Phone:619-266-3332
Mailing Address - Fax:619-266-6000
Practice Address - Street 1:292 EUCLID AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92114-3643
Practice Address - Country:US
Practice Address - Phone:619-266-3332
Practice Address - Fax:619-266-6000
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49164174400000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A491640Medicaid
CA00A491640Medicaid
CAF27762Medicare UPIN