Provider Demographics
NPI:1649292020
Name:DESOUZA, MICHAEL P (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:P
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 1:2521 JUNIOR ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8000
Mailing Address - Country:US
Mailing Address - Phone:386-774-5755
Mailing Address - Fax:386-774-0880
Practice Address - Street 1:2521 JUNIOR ST
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8000
Practice Address - Country:US
Practice Address - Phone:386-774-5755
Practice Address - Fax:386-774-0880
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME62917207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL371723200Medicaid
FL18295ZMedicare PIN
FL18295Medicare ID - Type Unspecified