Healthcare Provider Details

I. General information

NPI: 1982982864
Provider Name (Legal Business Name): WALLACY SOUZA GARCIA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2011
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3670 PARKER BLVD. STE 101
PUEBLO CO
81008-2285
US

IV. Provider business mailing address

PO BOX 560825
DENVER CO
80256-0825
US

V. Phone/Fax

Practice location:
  • Phone: 719-564-1544
  • Fax: 719-924-1592
Mailing address:
  • Phone: 719-595-7580
  • Fax: 719-545-0176

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberP77521
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberDR.0056470
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: