Basic Information
| Provider Information | |||||||||
| NPI: | 1790899458 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | D'SOUZA | ||||||||
| FirstName: | MARCELINO | ||||||||
| MiddleName: | FABIAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 908 NIAGARA FALLS BLVD STE 208 | ||||||||
| Address2: | |||||||||
| City: | NORTH TONAWANDA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 141202019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166923302 | ||||||||
| FaxNumber: | 7166924342 | ||||||||
| Practice Location | |||||||||
| Address1: | 8750 TRANSIT RD | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | EAST AMHERST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140512610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166397970 | ||||||||
| FaxNumber: | 7166397968 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 11/29/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 145872 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 00753975 | 05 | NY | MEDICAID |