Provider Demographics
NPI:1679527436
Name:DESOUZA, MARIA DEFATIMA (MD)
Entity type:Individual
Prefix:DR
First Name:MARIA
Middle Name:DEFATIMA
Last Name:DESOUZA
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:PO BOX 66500
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97290-6500
Mailing Address - Country:US
Mailing Address - Phone:503-657-8663
Mailing Address - Fax:503-723-3180
Practice Address - Street 1:2111 N. NORTHGATE WAY
Practice Address - Street 2:#201
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-0160
Practice Address - Country:US
Practice Address - Phone:206-365-5171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00016447207ZP0101X, 207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8168478Medicaid
WA1679527436OtherNPI NUMBER
WAG8803351Medicare PIN