Healthcare Provider Details

I. General information

NPI: 1992819700
Provider Name (Legal Business Name): EDUARDO A. DE SOUSA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 02/09/2021
Certification Date: 02/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 SW 4TH ST
MOORE OK
73160-2494
US

IV. Provider business mailing address

1060 SW 4TH ST
MOORE OK
73160-2494
US

V. Phone/Fax

Practice location:
  • Phone: 405-302-2661
  • Fax: 405-302-2670
Mailing address:
  • Phone: 405-302-2661
  • Fax: 405-302-2670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number27993
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD421598
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number27993
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number27993
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: