MEDICARE: DR. JERSLIN DE SOUSA DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NI0013X	Independent Medical Examiner Chiropractor	X0121739-1	NY
2	111N00000X	Chiropractor	X012739-1	NY

General Provider Information

NPI Number	:	1376053082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERSLIN DE SOUSA DC

Provider Business Mailing Address
First Line	:	1650 EASTERN PKWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11233-4804
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1650 EASTERN PKWY
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11233-4804
Country	:	US
Telephone Number	:	646-588-8000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/08/2017
Last Update Date	:	05/30/2019

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