Provider Demographics
NPI:1558321091
Name:DESTA, HIWOT B (MD)
Entity Type:Individual
Prefix:
First Name:HIWOT
Middle Name:B
Last Name:DESTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 RESTON AVE
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170
Mailing Address - Country:US
Mailing Address - Phone:703-723-3670
Mailing Address - Fax:703-723-8336
Practice Address - Street 1:19455 DEERFIELD AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-8446
Practice Address - Country:US
Practice Address - Phone:703-723-3670
Practice Address - Fax:703-723-8336
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236951207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
015976C69OtherDC MEDICARE
161650640OtherGROUP TAX ID #
3697025OtherAETNA HMO
7926400OtherAETNA PPO
243209OtherUNITED HEALTHCARE
VA171762OtherANTHEM BCBS
2108755OtherALLIANCE MAMSI OPT CHOICE
283656OtherAMERIGROUP
H9900002OtherCAREFIRST
VA010112109Medicaid
2101256OtherFIRST HEALTH
VA171762OtherANTHEM BCBS
H54204Medicare UPIN