Healthcare Provider Details

I. General information

NPI: 1972699205
Provider Name (Legal Business Name): TREVOR G DESOUZA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 02/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 LINDSLEY DR SUITE 205
MORRISTOWN NJ
07960-4455
US

IV. Provider business mailing address

402 LIPPINCOTT DR
MARLTON NJ
08053-4112
US

V. Phone/Fax

Practice location:
  • Phone: 973-993-8777
  • Fax: 973-993-8577
Mailing address:
  • Phone: 856-782-3300
  • Fax: 856-504-8029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number25MA04801800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: