Provider Demographics
NPI:1366705840
Name:DESELM, CARL J (MD)
Entity type:Individual
Prefix:DR
First Name:CARL
Middle Name:J
Last Name:DESELM
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7412011
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-2011
Mailing Address - Country:US
Mailing Address - Phone:314-747-7236
Mailing Address - Fax:314-362-8099
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:DEPT RADIATION ONCOLOGY, LL
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-747-7236
Practice Address - Fax:314-362-8099
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20180286782085R0001X
NY270926-1284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200063031Medicaid