Provider Demographics
NPI:1376738724
Name:SOUZA, KEVIN (DPM)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:SOUZA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3155 ROUTE 10 EAST
Mailing Address - Street 2:SUITE 215
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-3430
Mailing Address - Country:US
Mailing Address - Phone:973-895-3288
Mailing Address - Fax:
Practice Address - Street 1:3155 ROUTE 10 EAST
Practice Address - Street 2:SUITE 215
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-3430
Practice Address - Country:US
Practice Address - Phone:973-895-3288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00299100213ES0103X
CT000825213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ155683MS7Medicare PIN