Provider Demographics
NPI:1508841032
Name:DESTEFANO, JOSEPH ANTHONY JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:ANTHONY
Last Name:DESTEFANO
Suffix:JR
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 1:432 ARROWHEAD DR
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-5291
Mailing Address - Country:US
Mailing Address - Phone:423-557-2231
Mailing Address - Fax:
Practice Address - Street 1:800 N JUSTICE ST
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28791-3410
Practice Address - Country:US
Practice Address - Phone:828-694-7687
Practice Address - Fax:828-694-5763
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101251249207R00000X
TN38537207R00000X, 208M00000X
NC2003-00332207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1508841032Medicaid
GA230214777CMedicaid
NC1508841032Medicaid
TN3892268Medicaid
GA230214777BMedicaid
NCNC5448COtherMEDICARE PTAN
SCGP3988Medicaid
SCF935639342Medicare PIN
GA230214777BMedicaid
TXTXB161131Medicare PIN
VAVVE993AMedicare PIN
TN103I113017Medicare PIN