Provider Demographics
NPI:1518063734
Name:DESOUZA, MARIO L (MD)
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:L
Last Name:DESOUZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 8TH ST N
Mailing Address - Street 2:
Mailing Address - City:NEW ULM
Mailing Address - State:MN
Mailing Address - Zip Code:56073-1552
Mailing Address - Country:US
Mailing Address - Phone:507-217-5000
Mailing Address - Fax:507-217-5035
Practice Address - Street 1:1217 8TH ST N
Practice Address - Street 2:
Practice Address - City:NEW ULM
Practice Address - State:MN
Practice Address - Zip Code:56073-1552
Practice Address - Country:US
Practice Address - Phone:507-217-5000
Practice Address - Fax:507-217-5035
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29738207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN200000955Medicare ID - Type Unspecified
MNE63806Medicare UPIN