Provider Demographics
NPI:1043203839
Name:SOUZA, SANDRA L (MD)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:L
Last Name:SOUZA
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 1:2121A BELLEVUE RD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31021-2998
Mailing Address - Country:US
Mailing Address - Phone:478-272-1190
Mailing Address - Fax:478-275-6649
Practice Address - Street 1:2121A BELLEVUE RD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2998
Practice Address - Country:US
Practice Address - Phone:478-272-1190
Practice Address - Fax:478-274-7628
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039476207Q00000X
GA394762084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000606284HMedicaid
GA000666113DMedicaid
GA300030912AMedicaid
GA000666113DMedicaid
GA08BBWSWMedicare ID - Type Unspecified