Provider Demographics
NPI:1326202193
Name:W ALEXANDRA DA SOUZA MD PC
Entity Type:Organization
Organization Name:W ALEXANDRA DA SOUZA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:W
Authorized Official - Middle Name:ALEXANDRA
Authorized Official - Last Name:DA SOUZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-510-9100
Mailing Address - Street 1:124 ANDREWS WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-6860
Mailing Address - Country:US
Mailing Address - Phone:912-510-9100
Mailing Address - Fax:912-510-9269
Practice Address - Street 1:124 ANDREWS WAY
Practice Address - Street 2:SUITE A
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548-6860
Practice Address - Country:US
Practice Address - Phone:912-510-9100
Practice Address - Fax:912-510-9269
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA042556261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
B82783Medicare UPIN