Provider Demographics
NPI:1851884282
Name:DESTINE, JUNIOR MAX
Entity Type:Individual
Prefix:DR
First Name:JUNIOR
Middle Name:MAX
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 1:7513 MAPLE AVE APT 305
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-4949
Mailing Address - Country:US
Mailing Address - Phone:202-517-5529
Mailing Address - Fax:
Practice Address - Street 1:3663 SOUTH MIAMI AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133
Practice Address - Country:US
Practice Address - Phone:202-517-5529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-11
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26869208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice