Provider Demographics
NPI:1053394270
Name:DESOUSA, GARCIA JOSE (MD)
Entity type:Individual
Prefix:
First Name:GARCIA
Middle Name:JOSE
Last Name:DESOUSA
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 1:3334 66TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-1539
Mailing Address - Country:US
Mailing Address - Phone:727-341-1333
Mailing Address - Fax:727-347-8675
Practice Address - Street 1:3334 66TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1539
Practice Address - Country:US
Practice Address - Phone:727-341-1333
Practice Address - Fax:727-347-8675
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00405062084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL047747800Medicaid
D57453Medicare UPIN
110021283Medicare PIN
FL047747800Medicaid