Provider Demographics
NPI:1841786621
Name:D'SOUZA, RYAN (DO)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:D'SOUZA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 SIR THOMAS CT FL 2
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-4839
Mailing Address - Country:US
Mailing Address - Phone:717-657-3030
Mailing Address - Fax:
Practice Address - Street 1:805 SIR THOMAS CT FL 2
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-4839
Practice Address - Country:US
Practice Address - Phone:717-657-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-05
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT018336207Q00000X, 390200000X
PAOS020191207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1841786621Medicaid