Provider Demographics
NPI:1912929860
Name:DESOUZA-SANDERS, KELLY R (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:DESOUZA-SANDERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 WALNUT STREET
Mailing Address - Street 2:SUITE 220E PENNCARE FOR WOMENT
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-3304
Mailing Address - Country:US
Mailing Address - Phone:215-521-1400
Mailing Address - Fax:215-521-1422
Practice Address - Street 1:601 WALNUT STREET
Practice Address - Street 2:SUITE 220E PENNCARE FOR WOMENT
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-3304
Practice Address - Country:US
Practice Address - Phone:215-521-1400
Practice Address - Fax:215-521-1422
Is Sole Proprietor?:No
Enumeration Date:2006-07-23
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD045633207V00000X
PAMD045633L207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013459460001Medicaid
PA1013459460001Medicaid
PA093453Medicare PIN