Provider Demographics
NPI:1386623411
Name:DESTEFANO, PAOLO EMILIO (MD)
Entity type:Individual
Prefix:DR
First Name:PAOLO
Middle Name:EMILIO
Last Name:DESTEFANO
Suffix:
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 1:9001 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-5707
Mailing Address - Country:US
Mailing Address - Phone:718-748-2009
Mailing Address - Fax:718-748-2001
Practice Address - Street 1:9001 3RD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-5707
Practice Address - Country:US
Practice Address - Phone:718-748-2900
Practice Address - Fax:718-748-2538
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY133204207R00000X, 207RC0000X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00797351Medicaid
NYC10147Medicare UPIN
NY00797351Medicaid