Provider Demographics
NPI:1710107693
Name:FREEMAN, CARLOTTA VANESSA (MD)
Entity Type:Individual
Prefix:
First Name:CARLOTTA
Middle Name:VANESSA
Last Name:FREEMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:C
Other - Middle Name:
Other - Last Name:FREEMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, MBA
Mailing Address - Street 1:20 IRONSIDES ST
Mailing Address - Street 2:UNIT 1
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-5981
Mailing Address - Country:US
Mailing Address - Phone:310-512-7760
Mailing Address - Fax:310-512-7760
Practice Address - Street 1:2640 INDUSTRY WAY
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-4284
Practice Address - Country:US
Practice Address - Phone:310-627-4525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG847042084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G847040Medicaid
CAG84704Medicare ID - Type Unspecified
CA00G847040Medicaid