Healthcare Provider Details

I. General information

NPI: 1700030921
Provider Name (Legal Business Name): ASHWIN LUIS DESOUZA MBBS, MS, MRCSED, DN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2008
Last Update Date: 11/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 W. TAYLOR STREET UNIVERSITY OF ILLINOIS
CHICAGO IL
60612
US

IV. Provider business mailing address

1926 W. HARRISON STREET APARTMENT 506
CHICAGO IL
60612
US

V. Phone/Fax

Practice location:
  • Phone: 866-600-2273
  • Fax:
Mailing address:
  • Phone: 312-752-7106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number125055569
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: