Healthcare Provider Details

I. General information

NPI: 1558321091
Provider Name (Legal Business Name): HIWOT B DESTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19455 DEERFIELD AVE STE 201
LANSDOWNE VA
20176-8102
US

IV. Provider business mailing address

ONE GI CREDENTIALING DEPARTMENT PO BOX 381468
GERMANTOWN TN
38183-1468
US

V. Phone/Fax

Practice location:
  • Phone: 703-723-3670
  • Fax: 703-723-8336
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number0101236951
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: