MARK DESTACHE MD Medical Doctor License verification

Business Entity

ACTIVE

License Type

Medical Doctor

Description

LICENSED PHYSICIAN CONTROLLED SUBSTANCE

License Number

33*****42

License Status

ACTIVE

Business

Title

First Name

MARK

Last Name

DESTACHE

Business Name

MARK DESTACHE MD

Original Issue Date

04/06/2022

Effective Date

05/30/2023

Expiration Date

07/31/2026

City

SAINT PAUL

State

Zip

55105

Specialty/Qualifier

PRACTITIONER

Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

05/30/2023