Basic Information
Provider Information | |||||||||
NPI: | 1447408562 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DESTA | ||||||||
FirstName: | YENENEH | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WOLDETENSAYE | ||||||||
OtherFirstName: | YENENEH | ||||||||
OtherMiddleName: | D | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1600 LAKELAND HILLS BLVD | ||||||||
Address2: |   | ||||||||
City: | LAKELAND | ||||||||
State: | FL | ||||||||
PostalCode: | 338053065 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8636807000 | ||||||||
FaxNumber: | 8662648519 | ||||||||
Practice Location | |||||||||
Address1: | 1600 LAKELAND HILLS BLVD | ||||||||
Address2: |   | ||||||||
City: | LAKELAND | ||||||||
State: | FL | ||||||||
PostalCode: | 338053065 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8636807190 | ||||||||
FaxNumber: | 8662648519 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/03/2008 | ||||||||
LastUpdateDate: | 09/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 068635 | GA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RI0200X | 068635 | GA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | 208M00000X | 068635 | GA | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207RI0200X | ME109103 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.