Provider Demographics
NPI:1245694926
Name:DESOUZA, STEPHANIE (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:
Last Name:DESOUZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 VAN DYKE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-8005
Mailing Address - Country:US
Mailing Address - Phone:813-321-6237
Mailing Address - Fax:813-463-1801
Practice Address - Street 1:4211 VAN DYKE RD STE 200
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-8005
Practice Address - Country:US
Practice Address - Phone:813-321-6237
Practice Address - Fax:813-463-1801
Is Sole Proprietor?:No
Enumeration Date:2016-04-08
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME137758207R00000X, 208M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103762600Medicaid