Provider Demographics
NPI:1518014695
Name:DESTEPHANO, DON BERNARD (MD)
Entity Type:Individual
Prefix:
First Name:DON
Middle Name:BERNARD
Last Name:DESTEPHANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 144333
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-4333
Mailing Address - Country:US
Mailing Address - Phone:407-422-9831
Mailing Address - Fax:407-206-1767
Practice Address - Street 1:1 SHIRCLIFF WAY
Practice Address - Street 2:DEPT OF PATHOLOGY
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4748
Practice Address - Country:US
Practice Address - Phone:904-308-3803
Practice Address - Fax:904-308-2970
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME53628207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL064755100Medicaid
FL07937ZMedicare PIN
E21579Medicare UPIN