Provider Demographics
NPI:1700030921
Name:DESOUZA, ASHWIN LUIS (MBBS, MS, MRCSED, DN)
Entity Type:Individual
Prefix:
First Name:ASHWIN
Middle Name:LUIS
Last Name:DESOUZA
Suffix:
Gender:M
Credentials:MBBS, MS, MRCSED, DN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1926 W. HARRISON STREET
Mailing Address - Street 2:APARTMENT 506
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612
Mailing Address - Country:US
Mailing Address - Phone:312-752-7106
Mailing Address - Fax:
Practice Address - Street 1:1760 W. TAYLOR STREET
Practice Address - Street 2:UNIVERSITY OF ILLINOIS
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612
Practice Address - Country:US
Practice Address - Phone:866-600-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-14
Last Update Date:2008-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125055569390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program