Healthcare Provider Details

I. General information

NPI: 1639434475
Provider Name (Legal Business Name): JAIME SOU ROSA M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 11/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 CAMPUS DR CCSR 3215, MC 5366
STANFORD CA
94305-5101
US

IV. Provider business mailing address

269 CAMPUS DR CCSR 3215, MC 5366
STANFORD CA
94305-5101
US

V. Phone/Fax

Practice location:
  • Phone: 650-498-6073
  • Fax: 650-498-5560
Mailing address:
  • Phone: 650-498-6073
  • Fax: 650-498-5560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberA 121193
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA 121193
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: