Provider Demographics
NPI:1649246570
Name:LA CHARITE, DESIREE (MD)
Entity type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:LA CHARITE
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 1:2950 MOUNT WILKINSON PKWY SE
Mailing Address - Street 2:#604
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-3637
Mailing Address - Country:US
Mailing Address - Phone:608-829-5201
Mailing Address - Fax:
Practice Address - Street 1:5665 NEW NORTHSIDE DR NW
Practice Address - Street 2:SUITE 320
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-5831
Practice Address - Country:US
Practice Address - Phone:770-874-5400
Practice Address - Fax:770-874-5469
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43170207P00000X
GA062132207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34114500Medicaid
GA619228407EMedicaid
GA6192287407CMedicaid
GA202I939011Medicare PIN
GA202I939135Medicare PIN
WI34114500Medicaid
GA6192287407CMedicaid