Provider Demographics
NPI:1932225117
Name:DESTEFANO, JOHN A (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:DESTEFANO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:212 LOCHMORE RD
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-1302
Mailing Address - Country:US
Mailing Address - Phone:561-845-0634
Mailing Address - Fax:561-845-0634
Practice Address - Street 1:212 LOCHMORE RD
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-1302
Practice Address - Country:US
Practice Address - Phone:561-845-0634
Practice Address - Fax:561-845-0634
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO 1428213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL87762Medicare ID - Type Unspecified