Provider Demographics
NPI:1619915295
Name:D'SOUZA, GODWIN H (MD)
Entity Type:Individual
Prefix:
First Name:GODWIN
Middle Name:H
Last Name:D'SOUZA
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 1:5600 W ADDISON ST
Mailing Address - Street 2:LL001
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634
Mailing Address - Country:US
Mailing Address - Phone:773-202-9622
Mailing Address - Fax:773-283-0901
Practice Address - Street 1:5600 W ADDISON ST
Practice Address - Street 2:SUITE LL001
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-4401
Practice Address - Country:US
Practice Address - Phone:773-202-9622
Practice Address - Fax:773-283-0901
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036-091000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036091000Medicaid
IL597580Medicare PIN
ILG23795Medicare UPIN