Provider Demographics
NPI:1336135201
Name:DESOUZA, WILLIAM C (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:C
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 1:120 DAVY CROCKETT MALL
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:TN
Mailing Address - Zip Code:38382-2934
Mailing Address - Country:US
Mailing Address - Phone:731-855-2803
Mailing Address - Fax:731-855-1746
Practice Address - Street 1:120 DAVY CROCKETT MALL
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:TN
Practice Address - Zip Code:38382-2934
Practice Address - Country:US
Practice Address - Phone:731-855-2803
Practice Address - Fax:731-855-1746
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNMD8493207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3174197Medicaid
TN3174197Medicaid
3174197Medicare ID - Type Unspecified