Healthcare Provider Details

I. General information

NPI: 1699234997
Provider Name (Legal Business Name): TABITHA D'SOUZA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2019
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

WUSM PEDS, 1 CHILDRENS PL MSC 8116-0043-08
ST. LOUIS MO
63110
US

V. Phone/Fax

Practice location:
  • Phone: 314-617-2000
  • Fax:
Mailing address:
  • Phone: 314-454-4826
  • Fax: 314-454-4633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2025022352
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number2025022352
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: