Provider Demographics
NPI:1528521465
Name:CARMEN, DESIREE (MD)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:CARMEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3569 ROUND BARN CIR STE 200
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-5781
Mailing Address - Country:US
Mailing Address - Phone:707-583-8800
Mailing Address - Fax:
Practice Address - Street 1:210 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2517
Practice Address - Country:US
Practice Address - Phone:707-551-1818
Practice Address - Fax:707-645-1005
Is Sole Proprietor?:No
Enumeration Date:2019-04-08
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA181184207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA181184OtherSTATE MEDICAL LICENSE