Individual
MARK W DESERAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
3630 E. IMPERIAL HWY, LYNWOOD, CA 90262
(310) 900-2768
(310) 900-8852
Mailing address
3630 E. IMPERIAL HWY, LYNWOOD, CA 90262
(310) 900-2768
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
G67376
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00G673760
BLUE SHIELD OF CA
CA
05
—
00G673760
—
CA
Enumeration date
06/01/2006
Last updated
04/15/2011
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