Provider Demographics
NPI:1144277211
Name:SOUSA, ROLANDO (MD)
Entity type:Individual
Prefix:DR
First Name:ROLANDO
Middle Name:
Last Name:SOUSA
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 1:15 SHADOW RIDGE RUN
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-4956
Mailing Address - Country:US
Mailing Address - Phone:973-222-4653
Mailing Address - Fax:646-304-3194
Practice Address - Street 1:20 PROSPECT AVE
Practice Address - Street 2:SUITE 905
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1997
Practice Address - Country:US
Practice Address - Phone:973-222-4653
Practice Address - Fax:646-304-3194
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA0678032084N0402X
NJ25MA06780300208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0092886Medicaid
NJ100548B8AMedicare PIN