Basic Information
| Provider Information | |||||||||
| NPI: | 1003145087 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESTEFANO | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2489 DIPLOMAT PKWY E | ||||||||
| Address2: | |||||||||
| City: | CAPE CORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339095422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396521800 | ||||||||
| FaxNumber: | 2396521930 | ||||||||
| Practice Location | |||||||||
| Address1: | 2489 DIPLOMAT PKWY E | ||||||||
| Address2: | |||||||||
| City: | CAPE CORAL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339095422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396521800 | ||||||||
| FaxNumber: | 2396521930 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2009 | ||||||||
| LastUpdateDate: | 03/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | OS 10179 | FL | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.