Provider Demographics
NPI:1730126467
Name:DESERAN, MARK W (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:W
Last Name:DESERAN
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 1:3630 E. IMPERIAL HWY
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262
Mailing Address - Country:US
Mailing Address - Phone:310-900-2768
Mailing Address - Fax:
Practice Address - Street 1:3630 E. IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262
Practice Address - Country:US
Practice Address - Phone:310-900-2768
Practice Address - Fax:310-900-8852
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG673762085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G673760OtherBLUE SHIELD OF CA
CA00G673760Medicaid
CA00G673760Medicaid
CA300044564Medicare PIN
F63563Medicare UPIN
CAWG67376PMedicare PIN
CAWG67376BMedicare PIN
CA00G673760OtherBLUE SHIELD OF CA
CAWG67376QMedicare PIN
CAWG67376NMedicare PIN