Provider Demographics
NPI:1740276377
Name:DESOUSA, JOSE U (MD)
Entity type:Individual
Prefix:DR
First Name:JOSE
Middle Name:U
Last Name:DESOUSA
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 1:5141 OAKMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3714
Mailing Address - Country:US
Mailing Address - Phone:313-846-8840
Mailing Address - Fax:313-846-1540
Practice Address - Street 1:5141 OAKMAN BLVD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3714
Practice Address - Country:US
Practice Address - Phone:313-846-8840
Practice Address - Fax:313-846-1540
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301031739174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1529922Medicaid
MI382468447OtherTAX ID
MI0N91850002Medicare ID - Type Unspecified
MI1529922Medicaid