Healthcare Provider Details

I. General information

NPI: 1205321205
Provider Name (Legal Business Name): RANDAL DE SOUZA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2018
Last Update Date: 07/31/2025
Certification Date: 07/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S LIMESTONE STE K201
LEXINGTON KY
40536-2639
US

IV. Provider business mailing address

KENTUCKY CHILDREN'S HOSPITAL 800 ROSE ST
LEXINGTON KY
40536-0001
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-6211
  • Fax: 859-257-0491
Mailing address:
  • Phone: 859-323-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number60239
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35.144506
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: