Provider Demographics
NPI:1588638811
Name:DESTEFANI, THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:DESTEFANI
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 1:885 ROOSEVELT RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-6141
Mailing Address - Country:US
Mailing Address - Phone:630-790-1555
Mailing Address - Fax:630-545-3787
Practice Address - Street 1:885 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-6141
Practice Address - Country:US
Practice Address - Phone:630-790-1555
Practice Address - Fax:630-545-3787
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36067872208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036067872Medicaid
IL487450OtherMEDICARE PTAN (GROUP)
C46047Medicare UPIN
IL036067872Medicaid