Provider Demographics
NPI:1679565378
Name:DESOUZA, DEREK GEORGE (MD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:GEORGE
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 1:20206 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-1412
Mailing Address - Country:US
Mailing Address - Phone:248-476-4724
Mailing Address - Fax:248-476-7091
Practice Address - Street 1:20206 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1412
Practice Address - Country:US
Practice Address - Phone:248-476-4724
Practice Address - Fax:248-476-7091
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301042922207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1108211162OtherMEDICARE
MI1108211162OtherMEDICARE
MI3015105Medicare ID - Type Unspecified
MI0H26335Medicare ID - Type Unspecified