Provider Demographics
NPI:1588711618
Name:DESALLES, DOUGLAS EVERETT (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:EVERETT
Last Name:DESALLES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 SAN ANTONIO WAY
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-1927
Mailing Address - Country:US
Mailing Address - Phone:916-452-3357
Mailing Address - Fax:
Practice Address - Street 1:1801 E MARCH LN
Practice Address - Street 2:D-470
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-6629
Practice Address - Country:US
Practice Address - Phone:209-954-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53681207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine