Provider Demographics
NPI:1457823353
Name:MALCOLM DEPESTRE, DAVID MIGUEL (APRN)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:MIGUEL
Last Name:MALCOLM DEPESTRE
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:MIGUEL
Other - Last Name:MALCOLM DEPESTRE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:8510 WOODDRIFT DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-2041
Mailing Address - Country:US
Mailing Address - Phone:786-416-3807
Mailing Address - Fax:
Practice Address - Street 1:9740 N 56TH ST STE B
Practice Address - Street 2:
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33617-5500
Practice Address - Country:US
Practice Address - Phone:813-200-7717
Practice Address - Fax:813-985-8500
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-18
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11028306363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care