Basic Information
| Provider Information | |||||||||
| NPI: | 1043203839 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SOUZA | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2121A BELLEVUE RD | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310212998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782721190 | ||||||||
| FaxNumber: | 4782756649 | ||||||||
| Practice Location | |||||||||
| Address1: | 2121A BELLEVUE RD | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310212998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782721190 | ||||||||
| FaxNumber: | 4782747628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2005 | ||||||||
| LastUpdateDate: | 01/10/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 039476 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine | 2084P0800X | 39476 | GA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 000606284H | 05 | GA | MEDICAID | 000666113D | 05 | GA | MEDICAID | 300030912A | 05 | GA | MEDICAID |