Provider Demographics
NPI:1255100061
Name:DESTINE, MICHEL-ANGE EDOUARD
Entity type:Individual
Prefix:
First Name:MICHEL-ANGE
Middle Name:EDOUARD
Last Name:DESTINE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4513 NW 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3403
Mailing Address - Country:US
Mailing Address - Phone:202-855-1545
Mailing Address - Fax:
Practice Address - Street 1:4513 NW 31ST AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33309-3403
Practice Address - Country:US
Practice Address - Phone:202-855-1545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-21
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23-733246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant