Provider Demographics
NPI:1568578581
Name:DESOUZA, MALCOLM MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:MARK
Last Name:DESOUZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4910 MASSACHUSETTS AVE NW
Mailing Address - Street 2:SUITE 307
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20016-4300
Mailing Address - Country:US
Mailing Address - Phone:202-237-8633
Mailing Address - Fax:202-237-8632
Practice Address - Street 1:4910 MASSACHUSETTS AVE NW
Practice Address - Street 2:SUITE 307
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20016-4300
Practice Address - Country:US
Practice Address - Phone:202-237-8633
Practice Address - Fax:202-237-8632
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD20701207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F84052Medicare UPIN
G01775Medicare ID - Type Unspecified