Provider Demographics
NPI:1114260619
Name:DESTEFANO, SAMUEL FISK (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:FISK
Last Name:DESTEFANO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7780 S BROADWAY STE 350
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80122-2641
Mailing Address - Country:US
Mailing Address - Phone:303-730-4400
Mailing Address - Fax:303-730-4401
Practice Address - Street 1:7780 S BROADWAY STE 350
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80122-2641
Practice Address - Country:US
Practice Address - Phone:303-730-4400
Practice Address - Fax:303-730-4401
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00581442084N0400X
CODR.00581442084N0600X, 2084E0001X
COCDRH.00581442084E0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084E0001XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyEpilepsy
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology