Provider Demographics
NPI:1699735530
Name:DESOUZA, ALEXANDRE (MD)
Entity type:Individual
Prefix:
First Name:ALEXANDRE
Middle Name:
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 1:200 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:WV
Mailing Address - Zip Code:25276-1050
Mailing Address - Country:US
Mailing Address - Phone:304-927-6844
Mailing Address - Fax:304-927-6807
Practice Address - Street 1:200 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:WV
Practice Address - Zip Code:25276-1050
Practice Address - Country:US
Practice Address - Phone:304-927-6844
Practice Address - Fax:304-927-6807
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV18860207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0114172000Medicaid
WV1922068469Medicaid
WV1922068469Medicaid
WVG61328Medicare UPIN