Provider Demographics
NPI:1154761252
Name:KESTILA, DEREK DAVID (DO)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:DAVID
Last Name:KESTILA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:300 SINGLETON RIDGE ROAD
Mailing Address - Street 2:ATTENTION PNS CREDENTIALING
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-9142
Mailing Address - Country:US
Mailing Address - Phone:843-234-6946
Mailing Address - Fax:
Practice Address - Street 1:6010 HIGHWAY 707
Practice Address - Street 2:STE 100
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-7321
Practice Address - Country:US
Practice Address - Phone:843-234-8939
Practice Address - Fax:843-234-8959
Is Sole Proprietor?:No
Enumeration Date:2013-07-03
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC83469207Q00000X
PAOT015437207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC834690Medicaid