Provider Demographics
NPI:1740254150
Name:SOUZA, MICHAEL C (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:C
Last Name: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 1:1275 WAMPANOAG TRL
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:RI
Mailing Address - Zip Code:02915-1217
Mailing Address - Country:US
Mailing Address - Phone:401-437-0120
Mailing Address - Fax:401-424-4155
Practice Address - Street 1:1275 WAMPANOAG TRL
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-1217
Practice Address - Country:US
Practice Address - Phone:401-437-0120
Practice Address - Fax:401-424-4155
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI00446202D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No202D00000XAllopathic & Osteopathic PhysiciansIntegrative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI89020288Medicare ID - Type Unspecified
RIF41773Medicare UPIN