Provider Demographics
NPI:1750369153
Name:DSOUZA, SANDEEP C (MD)
Entity type:Individual
Prefix:
First Name:SANDEEP
Middle Name:C
Last Name:DSOUZA
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:PO BOX 1528
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:GA
Mailing Address - Zip Code:31040-1528
Mailing Address - Country:US
Mailing Address - Phone:478-272-1366
Mailing Address - Fax:478-275-2322
Practice Address - Street 1:104 FAIRVIEW PARK DR
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021
Practice Address - Country:US
Practice Address - Phone:478-272-1366
Practice Address - Fax:478-275-2322
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA044439207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA5111446OtherFIRST HEALTH
GA000766092AMedicaid
GA1795241OtherUNITED HEALTHCARE
GA52650905-001OtherBCBS
GA7359314OtherAETNA
GA11BDMZHMedicare PIN
GA7359314OtherAETNA