Provider Demographics
NPI:1588796320
Name:DESTEFANO, MICHAEL DON (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DON
Last Name:DESTEFANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12504 SOUTHWEST HWY
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-1851
Mailing Address - Country:US
Mailing Address - Phone:708-214-9281
Mailing Address - Fax:708-361-4570
Practice Address - Street 1:7000 W 111TH ST
Practice Address - Street 2:
Practice Address - City:WORTH
Practice Address - State:IL
Practice Address - Zip Code:60482-1851
Practice Address - Country:US
Practice Address - Phone:708-361-0100
Practice Address - Fax:708-361-2742
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics