Provider Demographics
NPI:1225069313
Name:DESSUREAULT, SOPHIE (MD, PHD)
Entity type:Individual
Prefix:
First Name:SOPHIE
Middle Name:
Last Name:DESSUREAULT
Suffix:
Gender:F
Credentials:MD, PHD
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 198441
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8441
Mailing Address - Country:US
Mailing Address - Phone:813-745-7365
Mailing Address - Fax:813-449-8618
Practice Address - Street 1:12902 USF MAGNOLIA DR
Practice Address - Street 2:MDC 44
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9416
Practice Address - Country:US
Practice Address - Phone:813-745-3980
Practice Address - Fax:813-903-6817
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87239208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262778700Medicaid
FL03304OtherBLUE CROSS BLUE SHIELD
FLH47637Medicare UPIN