Basic Information
| Provider Information | |||||||||
| NPI: | 1457503666 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DESSALINES | ||||||||
| FirstName: | DUCLOS | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2601 10TH AVE N | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | PALM SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334613133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616591270 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7408 LAKE WORTH RD | ||||||||
| Address2: | |||||||||
| City: | LAKE WORTH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334672502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5613701320 | ||||||||
| FaxNumber: | 5613701390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2008 | ||||||||
| LastUpdateDate: | 01/12/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME102516 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1769900 | 05 | FL | MEDICAID |