Provider Demographics
NPI:1316130594
Name:V JOHN D SOUZA MD SC
Entity type:Organization
Organization Name:V JOHN D SOUZA MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENT/REPRESENTATIVE
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:COOLIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-774-5211
Mailing Address - Street 1:PO BOX 741240
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32774-1240
Mailing Address - Country:US
Mailing Address - Phone:386-774-5211
Mailing Address - Fax:386-774-5251
Practice Address - Street 1:576 STERTHAUS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5128
Practice Address - Country:US
Practice Address - Phone:386-677-5674
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME55087207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00277876OtherRAILROAD MEDICARE
FL064866300Medicaid
FL11659EOtherMEDICARE INDIVIDUAL PIN
FLDE1997OtherRAILROAD MEDICARE
FL11659OtherBCBS NUMBER
FL11659EOtherMEDICARE INDIVIDUAL PIN
P00277876OtherRAILROAD MEDICARE