Provider Demographics
NPI:1437764313
Name:DE SOUZA, ALAN ATOGAMIS (PT)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:ATOGAMIS
Last Name:DE SOUZA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1656 WILKINSON WAY SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-1604
Mailing Address - Country:US
Mailing Address - Phone:206-566-1078
Mailing Address - Fax:
Practice Address - Street 1:500 N SEMORAN BLVD STE 101
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-3381
Practice Address - Country:US
Practice Address - Phone:407-815-6555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2022-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT012759225700000X
FLPT39673225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA99739OtherMEDICAL LICENSE
FLPT39673OtherMEDICAL LICENSE