Provider Demographics
NPI:1679703235
Name:DESKIN, JUSTIN NMN (DO)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:NMN
Last Name:DESKIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:JUSTIN
Other - Middle Name:DESKIN
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PSC 836 BOX 196
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09636-9998
Mailing Address - Country:US
Mailing Address - Phone:850-501-7736
Mailing Address - Fax:
Practice Address - Street 1:NMRTC SIGONELLA
Practice Address - Street 2:
Practice Address - City:SIGONELLA
Practice Address - State:SIGONELLA
Practice Address - Zip Code:11530
Practice Address - Country:IT
Practice Address - Phone:314-246-4771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-16
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5153207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1679703235Medicaid