Healthcare Provider Details

I. General information

NPI: 1558623181
Provider Name (Legal Business Name): JUDITH SOUSA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JUDITH LORENZO MD

II. Dates (important events)

Enumeration Date: 06/11/2012
Last Update Date: 04/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 2ND ST
LAKEWOOD NJ
08701-3324
US

IV. Provider business mailing address

101 2ND ST
LAKEWOOD NJ
08701-3324
US

V. Phone/Fax

Practice location:
  • Phone: 732-363-6655
  • Fax: 732-363-6656
Mailing address:
  • Phone: 732-363-6655
  • Fax: 732-363-6656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA09084100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: