Provider Demographics
NPI:1366162810
Name:DE SOUSA, JOSE NILDO
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:NILDO
Last Name:DE SOUSA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 BRIDGEWAY STE A1
Mailing Address - Street 2:
Mailing Address - City:SAUSALITO
Mailing Address - State:CA
Mailing Address - Zip Code:94965-2182
Mailing Address - Country:US
Mailing Address - Phone:415-858-3833
Mailing Address - Fax:
Practice Address - Street 1:1001 BRIDGEWAY STE A1
Practice Address - Street 2:#178
Practice Address - City:SAUSALITO
Practice Address - State:CA
Practice Address - Zip Code:94965-2182
Practice Address - Country:US
Practice Address - Phone:415-858-3833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-02
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE175514146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic