Provider Demographics
NPI:1053378067
Name:DESTEFANO, DOMINICK A (AT,C)
Entity type:Individual
Prefix:MR
First Name:DOMINICK
Middle Name:A
Last Name:DESTEFANO
Suffix:
Gender:M
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:HAMPTON BAYS
Mailing Address - State:NY
Mailing Address - Zip Code:11946-2657
Mailing Address - Country:US
Mailing Address - Phone:631-723-1041
Mailing Address - Fax:
Practice Address - Street 1:1370A MAJORS PATH
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-2416
Practice Address - Country:US
Practice Address - Phone:631-259-0400
Practice Address - Fax:631-259-0404
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000572-12255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer