Provider Demographics
NPI:1962248211
Name:D SOUZA, GLEN (MD)
Entity type:Individual
Prefix:DR
First Name:GLEN
Middle Name:
Last Name:D SOUZA
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 1:1611 W HARRISON ST STE 550
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4861
Mailing Address - Country:US
Mailing Address - Phone:312-942-6100
Mailing Address - Fax:312-942-6653
Practice Address - Street 1:1611 W HARRISON ST STE 550
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4861
Practice Address - Country:US
Practice Address - Phone:312-942-6100
Practice Address - Fax:312-942-6653
Is Sole Proprietor?:No
Enumeration Date:2024-07-06
Last Update Date:2024-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085013207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology