Provider Demographics
NPI:1558321091
Name:DESTA, HIWOT B (MD)
Entity type:Individual
Prefix:
First Name:HIWOT
Middle Name:B
Last Name:DESTA
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:ONE GI CREDENTIALING DEPARTMENT
Mailing Address - Street 2:PO BOX 381468
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38183-1468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19455 DEERFIELD AVE STE 201
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:VA
Practice Address - Zip Code:20176-8102
Practice Address - Country:US
Practice Address - Phone:703-723-3670
Practice Address - Fax:703-723-8336
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236951207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010112109Medicaid
161650640OtherGROUP TAX ID #
3697025OtherAETNA HMO
7926400OtherAETNA PPO
243209OtherUNITED HEALTHCARE
VA171762OtherANTHEM BCBS
2108755OtherALLIANCE MAMSI OPT CHOICE
283656OtherAMERIGROUP
H9900002OtherCAREFIRST
VA010112109Medicaid
2101256OtherFIRST HEALTH
VA171762OtherANTHEM BCBS
H54204Medicare UPIN