Basic Information
| Provider Information | |||||||||
| NPI: | 1326492547 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | D'SOUZA | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | FREDERICK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 LIND AVE SW | ||||||||
| Address2: | SUITE 100 ATTN CREDENTIALING | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980574970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256902715 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 S 43RD ST | ||||||||
| Address2: | |||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980555714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252283440 | ||||||||
| FaxNumber: | 4256564214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2016 | ||||||||
| LastUpdateDate: | 05/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD60951959 | WA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | MD60951959 | WA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | G8998818 | 01 | WA | MEDICARE W VALLEY MEDICAL GROUP - RENTON | OTHER | 2138091 | 05 | WA | MEDICAID |