Healthcare Provider Details

I. General information

NPI: 1366474694
Provider Name (Legal Business Name): LOUIS M DESTEFANO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 CHESTERBROOK BLVD SUITE 200
BERWYN PA
19312-3805
US

IV. Provider business mailing address

1001 CHESTERBROOK BLVD SUITE 200
BERWYN PA
19312-3805
US

V. Phone/Fax

Practice location:
  • Phone: 610-576-7500
  • Fax: 610-353-2140
Mailing address:
  • Phone: 310-576-7500
  • Fax: 610-353-2140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD039970L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: