Provider Demographics
NPI:1760582605
Name:DESALVO, CAROLYN (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:
Last Name:DESALVO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CAROLYN
Other - Middle Name:NAN
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1321 3 CRABS RD
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-7856
Mailing Address - Country:US
Mailing Address - Phone:785-727-9173
Mailing Address - Fax:
Practice Address - Street 1:346 N SEQUIM AVENUE
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382
Practice Address - Country:US
Practice Address - Phone:360-504-3243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-24152207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E10822Medicare UPIN