Provider Demographics
NPI:1710953294
Name:DESOUZA, ROMALDO (MD)
Entity Type:Individual
Prefix:
First Name:ROMALDO
Middle Name:
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 1:12032 WINDING CREEK CT
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:VA
Mailing Address - Zip Code:20124-2242
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6344 TRED AVON PLACE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155
Practice Address - Country:US
Practice Address - Phone:703-217-6255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-24
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101128303207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA211234OtherTRIGON BC NUMBER
MD53309413OtherCAREFIRST BC NUMBER
VA005824184Medicaid
DC017717400Medicaid
DC0006OtherCAREFIRST BC OF NCA NUMBE
MD559930001Medicaid
VA002146G65Medicare ID - Type Unspecified
MD53309413OtherCAREFIRST BC NUMBER
DC415446G87Medicare ID - Type Unspecified
DC0006OtherCAREFIRST BC OF NCA NUMBE