Provider Demographics
NPI:1194775874
Name:DE SOUZA, LUCIARA (MD)
Entity type:Individual
Prefix:DR
First Name:LUCIARA
Middle Name:
Last Name:DE SOUZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LUCIARA
Other - Middle Name:
Other - Last Name:MENDENHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:801 6TH ST S
Mailing Address - Street 2:DEPT 6941
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4816
Mailing Address - Country:US
Mailing Address - Phone:727-767-4971
Mailing Address - Fax:727-767-4970
Practice Address - Street 1:801 6TH ST S
Practice Address - Street 2:DEPT 6941
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4816
Practice Address - Country:US
Practice Address - Phone:727-767-4971
Practice Address - Fax:727-767-4970
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90793208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH91046Medicare UPIN