Healthcare Provider Details

I. General information

NPI: 1275534158
Provider Name (Legal Business Name): JOSE C DE SOUZA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 WINDWARD WAY STE 100
KALISPELL MT
59901-2619
US

IV. Provider business mailing address

430 WINDWARD WAY STE 100
KALISPELL MT
59901-2619
US

V. Phone/Fax

Practice location:
  • Phone: 406-751-5364
  • Fax: 406-751-5367
Mailing address:
  • Phone: 406-751-5364
  • Fax: 406-751-5367

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number8767
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: