Individual
DR. MARK T DESTACHE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
333 SMITH AVE N, SAINT PAUL, MN 55102-2344
(651) 735-0501
(651) 735-1870
Mailing address
8681 EAGLE POINT BLVD, LAKE ELMO, MN 55042-8628
(651) 251-8021
(651) 251-8050
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
036159952
IL
207L00000X
Anesthesiology Physician
Primary
34185
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
581807900
—
MN
Enumeration date
08/31/2006
Last updated
08/02/2022
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