Provider Demographics
NPI:1023129483
Name:DESTACHE, MARK T (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:DESTACHE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:8681 EAGLE POINT BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-8628
Mailing Address - Country:US
Mailing Address - Phone:651-251-8021
Mailing Address - Fax:651-251-8050
Practice Address - Street 1:333 SMITH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2344
Practice Address - Country:US
Practice Address - Phone:651-735-0501
Practice Address - Fax:651-735-1870
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2022-08-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036159952207L00000X
MN34185207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN581807900Medicaid
E71238Medicare UPIN
MN050000405Medicare ID - Type Unspecified