Provider Demographics
NPI:1427138486
Name:DESOUZA, BRYAN XAVIER (MD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:XAVIER
Last Name:DESOUZA
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 1:100 E LANCASTER AVE
Mailing Address - Street 2:SUITE 312
Mailing Address - City:WYNNEWOOD
Mailing Address - State:PA
Mailing Address - Zip Code:19096-3450
Mailing Address - Country:US
Mailing Address - Phone:610-649-6090
Mailing Address - Fax:610-640-6087
Practice Address - Street 1:100 E LANCASTER AVE
Practice Address - Street 2:SUITE 312
Practice Address - City:WYNNEWOOD
Practice Address - State:PA
Practice Address - Zip Code:19096-3450
Practice Address - Country:US
Practice Address - Phone:610-649-6090
Practice Address - Fax:610-640-6087
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD052950L2084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Not Answered2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0727230000OtherKEYSTONE HEALTH PLAN EAST
PA481009OtherAETNA
PA1483921Medicaid
PA0792085-007OtherCIGNA
PA438218OtherAMERIHEALTH/KEYSTONE
PADE438218OtherBLUE CROSS BLUE SHIELD
PADE438218OtherBLUE SHIELD
PA0727230000OtherKEYSTONE HEALTH PLAN EAST
PA1483921Medicaid