Basic Information
| Provider Information | |||||||||
| NPI: | 1508841032 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESTEFANO | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 432 ARROWHEAD DR | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376645291 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4235572231 | ||||||||
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| Practice Location | |||||||||
| Address1: | 800 N JUSTICE ST | ||||||||
| Address2: | |||||||||
| City: | HENDERSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287913410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286947687 | ||||||||
| FaxNumber: | 8286945763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0101251249 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 38537 | TN | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 38537 | TN | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 2003-00332 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1508841032 | 05 | VA | MEDICAID | 230214777C | 05 | GA | MEDICAID | 1508841032 | 05 | NC | MEDICAID | 3892268 | 05 | TN | MEDICAID | 230214777B | 05 | GA | MEDICAID | NC5448C | 01 | NC | MEDICARE PTAN | OTHER | GP3988 | 05 | SC | MEDICAID |