Basic Information
Provider Information
NPI: 1003145087
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DESTEFANO
FirstName: LAURA
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: DO
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2484 CARING WAY
Address2: SUITE C
City: PORT CHARLOTTE
State: FL
PostalCode: 339525306
CountryCode: US
TelephoneNumber: 9412352111
FaxNumber: 9412352112
Practice Location
Address1: 2484 CARING WAY
Address2: SUITE C
City: PORT CHARLOTTE
State: FL
PostalCode: 339525306
CountryCode: US
TelephoneNumber: 9412352111
FaxNumber: 9412352112
Other Information
ProviderEnumerationDate: 12/21/2009
LastUpdateDate: 03/17/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207N00000XOS 10179FLY Allopathic & Osteopathic PhysiciansDermatology 

No ID Information.


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