Provider Demographics
NPI:1205235371
Name:RALPH, IDESTA
Entity type:Individual
Prefix:
First Name:IDESTA
Middle Name:
Last Name:RALPH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5530 OLD NATIONAL HWY BLDG 5530-B2
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30349-6234
Mailing Address - Country:US
Mailing Address - Phone:470-818-2264
Mailing Address - Fax:866-984-3729
Practice Address - Street 1:5530 OLD NATIONAL HWY BLDG 5530-B2
Practice Address - Street 2:
Practice Address - City:COLLEGE PARK
Practice Address - State:GA
Practice Address - Zip Code:30349-3356
Practice Address - Country:US
Practice Address - Phone:470-818-2264
Practice Address - Fax:866-984-3729
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY56083246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy