Provider Demographics
NPI:1255342952
Name:DESOLMINIHAC, MARC CARLETON (MD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:CARLETON
Last Name:DESOLMINIHAC
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 1:6353 CENTER DR
Mailing Address - Street 2:SUITE 204
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-4112
Mailing Address - Country:US
Mailing Address - Phone:757-461-3313
Mailing Address - Fax:757-461-8363
Practice Address - Street 1:6353 CENTER DRIVE
Practice Address - Street 2:SUITE 204
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502
Practice Address - Country:US
Practice Address - Phone:757-461-3313
Practice Address - Fax:757-461-8363
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0372162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA26000726Medicare ID - Type Unspecified
VAB59753Medicare UPIN