Provider Demographics
NPI:1770131849
Name:DESRAVINES, MEDZDABE (LAC, MSTOM, DIPL)
Entity type:Individual
Prefix:
First Name:MEDZDABE
Middle Name:
Last Name:DESRAVINES
Suffix:
Gender:M
Credentials:LAC, MSTOM, DIPL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 OCEAN PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-4104
Mailing Address - Country:US
Mailing Address - Phone:718-885-6671
Mailing Address - Fax:
Practice Address - Street 1:200 OLD COUNTRY RD STE 140
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4273
Practice Address - Country:US
Practice Address - Phone:516-794-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-30
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006601-01171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist