Provider Demographics
NPI:1447408562
Name:DESTA, YENENEH (MD)
Entity Type:Individual
Prefix:DR
First Name:YENENEH
Middle Name:
Last Name:DESTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:YENENEH
Other - Middle Name:D
Other - Last Name:WOLDETENSAYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1600 LAKELAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-3065
Mailing Address - Country:US
Mailing Address - Phone:863-680-7000
Mailing Address - Fax:866-264-8519
Practice Address - Street 1:1600 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3065
Practice Address - Country:US
Practice Address - Phone:863-680-7190
Practice Address - Fax:866-264-8519
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME109103207RI0200X, 207RI0200X
GA068635207RI0200X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003800400Medicaid