Provider Demographics
NPI:1588805121
Name:DE WALT, CAROL NICOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:NICOLE
Last Name:DE WALT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CAROL
Other - Middle Name:NICOLE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2390 CRENSHAW BLVD UNIT 708
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-3300
Mailing Address - Country:US
Mailing Address - Phone:310-270-7747
Mailing Address - Fax:
Practice Address - Street 1:3330 LOMITA BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5002
Practice Address - Country:US
Practice Address - Phone:310-270-7477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-11
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95208208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics