Basic Information
| Provider Information | |||||||||
| NPI: | 1790928216 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESTEFANO | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | LEONARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 SIERRA DR | ||||||||
| Address2: | SUITE 400 ATTN: MARY DEAN | ||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 461437240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178658797 | ||||||||
| FaxNumber: | 3178598552 | ||||||||
| Practice Location | |||||||||
| Address1: | 1116 N 16TH ST | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479042119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654236300 | ||||||||
| FaxNumber: | 7654236301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2009 | ||||||||
| LastUpdateDate: | 12/28/2016 | ||||||||
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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 | 2084P0800X | 01042109A | IN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 201069420L | 05 | IN | MEDICAID | 200080730 | 05 | IN | MEDICAID |