Provider Demographics
NPI:1225417397
Name:D SOUZA, PREMA FANCY (MD)
Entity Type:Individual
Prefix:
First Name:PREMA
Middle Name:FANCY
Last Name:D 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 1:2401 GILLHAM RD
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64108-4619
Mailing Address - Country:US
Mailing Address - Phone:816-701-5200
Mailing Address - Fax:816-302-9939
Practice Address - Street 1:20300 E VALLEY VIEW PKWY
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057
Practice Address - Country:US
Practice Address - Phone:816-478-5200
Practice Address - Fax:816-302-9939
Is Sole Proprietor?:No
Enumeration Date:2015-05-22
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018028464208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics