Provider Demographics
NPI:1073541538
Name:SOUSA, ANN M (DO)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:M
Last Name:SOUSA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MAIN ST
Mailing Address - Street 2:PO BOX 636
Mailing Address - City:HEBRON
Mailing Address - State:CT
Mailing Address - Zip Code:06248-1519
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 MAIN ST
Practice Address - Street 2:
Practice Address - City:HEBRON
Practice Address - State:CT
Practice Address - Zip Code:06248-1519
Practice Address - Country:US
Practice Address - Phone:860-228-1119
Practice Address - Fax:860-228-4314
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041639207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT5999285OtherCIGNA
CT2V6789OtherHEALTH NET
CT041639OtherCONNECTICARE
CT040041639CT04OtherANTHEM BC & BS OF CT
CT3425912OtherAETNA
CT041639OtherCONNECTICARE