Provider Demographics
NPI:1407212020
Name:DE SOUZA, KOFFI
Entity Type:Individual
Prefix:
First Name:KOFFI
Middle Name:
Last Name:DE SOUZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9287 NIEMAN RD
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66214-1807
Mailing Address - Country:US
Mailing Address - Phone:913-937-6819
Mailing Address - Fax:
Practice Address - Street 1:9287 NIEMAN RD
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66214-1807
Practice Address - Country:US
Practice Address - Phone:913-937-6819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-12
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS201122490B172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver