1316130594 NPI number — V JOHN D SOUZA MD SC

Table of content: (NPI 1316130594)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316130594 NPI number — V JOHN D SOUZA MD SC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
V JOHN D SOUZA MD SC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316130594
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 741240
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32774-1240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-774-5211
Provider Business Mailing Address Fax Number:
386-774-5251

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
576 STERTHAUS AVE
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
ORMOND BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32174-5128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-677-5674
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
COOLIDGE
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
AGENT/REPRESENTATIVE
Authorized Official Telephone Number:
386-774-5211

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  ME55087 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00277876 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 064866300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 11659E . This is a "MEDICARE INDIVIDUAL PIN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: DE1997 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 11659 . This is a "BCBS NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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