Provider Demographics
NPI:1558793422
Name:SOUZA, FABIOLA GAZONI DE (MD)
Entity Type:Individual
Prefix:
First Name:FABIOLA
Middle Name:GAZONI DE
Last Name:SOUZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 COLUMBUS PL
Mailing Address - Street 2:N 37A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-8201
Mailing Address - Country:US
Mailing Address - Phone:917-991-6924
Mailing Address - Fax:
Practice Address - Street 1:5645 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5045
Practice Address - Country:US
Practice Address - Phone:718-670-1341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-02
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY268167207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG400105921Medicare PIN