Provider Demographics
NPI:1912934464
Name:CARSON, DESMOND EARL (MD)
Entity Type:Individual
Prefix:
First Name:DESMOND
Middle Name:EARL
Last Name:CARSON
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 1:3629 RIDGEWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94806-1943
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:SUTTER SOLANO MEDICAL CENTER
Practice Address - Street 2:300 HOSPITAL DRIVE
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589
Practice Address - Country:US
Practice Address - Phone:707-554-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60476207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A604760Medicaid
CA00A604760Medicare PIN
CAG48868Medicare UPIN
CA00A604761Medicare PIN
CA00A604762Medicare PIN