Basic Information
| Provider Information | |||||||||
| NPI: | 1104098789 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | D'SOUZA | ||||||||
| FirstName: | BERNARD | ||||||||
| MiddleName: | TUODOR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | D'SOUZA | ||||||||
| OtherFirstName: | BERNARD | ||||||||
| OtherMiddleName: | TUODOR | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 56 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067061253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037096000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 56 FRANKLIN ST | ||||||||
| Address2: | ST MARY'S HOSPITAL , DEPARTMENT OF MEDICINE | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067061253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037096424 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2008 | ||||||||
| LastUpdateDate: | 10/22/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 048267 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 48267 | CT | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 9852543 | 01 | CT | AETNA | OTHER | 61470493 | 01 | CT | UHC | OTHER | 008017075 | 05 | CT | MEDICAID | 1137283 | 01 | CT | WELLCARE | OTHER |