Provider Demographics
NPI:1013944792
Name:CARLSON, DESIREE A (MD)
Entity Type:Individual
Prefix:DR
First Name:DESIREE
Middle Name:A
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 CENTRE ST
Mailing Address - Street 2:PATHOLOGY DEPARTMENT
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3395
Mailing Address - Country:US
Mailing Address - Phone:508-941-7414
Mailing Address - Fax:508-941-6295
Practice Address - Street 1:680 CENTRE ST
Practice Address - Street 2:PATHOLOGY DEPARTMENT
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-3395
Practice Address - Country:US
Practice Address - Phone:508-941-7414
Practice Address - Fax:508-941-6295
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA058260207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3027244Medicaid
MAJ06599Medicare ID - Type Unspecified
MA3027244Medicaid