Provider Demographics
NPI:1639579923
Name:DUCLOS DESSALINES
Entity type:Organization
Organization Name:DUCLOS DESSALINES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:DUCLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:DESSALINES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:561-703-3716
Mailing Address - Street 1:4519 LAKE WORTH RD
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33463-3449
Mailing Address - Country:US
Mailing Address - Phone:561-432-8300
Mailing Address - Fax:
Practice Address - Street 1:4519 LAKE WORTH RD
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33463-3449
Practice Address - Country:US
Practice Address - Phone:561-432-8300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-25
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 102516173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001769900Medicaid