Provider Demographics
NPI:1992748495
Name:DESIDERIO, CARL (DO)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:
Last Name:DESIDERIO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W 23RD ST
Mailing Address - Street 2:APT N 10 P
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-1011
Mailing Address - Country:US
Mailing Address - Phone:212-731-2187
Mailing Address - Fax:
Practice Address - Street 1:555 W 23RD ST
Practice Address - Street 2:APT N 10 P
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-1011
Practice Address - Country:US
Practice Address - Phone:212-731-2187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB03344700207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1949306Medicaid
NJ1949306Medicaid
NJ455401TFAMedicare ID - Type Unspecified