Provider Demographics
NPI:1790928216
Name:DESTEFANO, JOSEPH LEONARD (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:LEONARD
Last Name:DESTEFANO
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 1:1040 SIERRA DR
Mailing Address - Street 2:SUITE 400 ATTN: MARY DEAN
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-7240
Mailing Address - Country:US
Mailing Address - Phone:317-865-8797
Mailing Address - Fax:317-859-8552
Practice Address - Street 1:1116 N 16TH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2119
Practice Address - Country:US
Practice Address - Phone:765-423-6300
Practice Address - Fax:765-423-6301
Is Sole Proprietor?:No
Enumeration Date:2009-04-14
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042109A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201069420LMedicaid
IN200080730Medicaid
IN200080730Medicaid