Provider Demographics
NPI:1174612576
Name:DESTEFANO, ROBERT (MD)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:DESTEFANO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 PIN OAK DR.
Mailing Address - Street 2:
Mailing Address - City:BAYTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:77520-1217
Mailing Address - Country:US
Mailing Address - Phone:281-427-8255
Mailing Address - Fax:281-422-9973
Practice Address - Street 1:306 PIN OAK DR.
Practice Address - Street 2:
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77520-1217
Practice Address - Country:US
Practice Address - Phone:281-427-8255
Practice Address - Fax:281-422-9973
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF6222207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0347049-01Medicaid
00LH49Medicare ID - Type Unspecified