Provider Demographics
NPI:1255678355
Name:MICHAEL P DESOUZA MD PA
Entity Type:Organization
Organization Name:MICHAEL P DESOUZA MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:DESOUZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:386-774-5755
Mailing Address - Street 1:2521 JUNIOR ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8000
Mailing Address - Country:US
Mailing Address - Phone:386-774-5755
Mailing Address - Fax:386-774-0880
Practice Address - Street 1:2521 JUNIOR ST
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8000
Practice Address - Country:US
Practice Address - Phone:386-774-5755
Practice Address - Fax:386-774-0880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-09
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0062917207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371723200Medicaid
FL371723200Medicaid
FL18295Medicare PIN