Provider Demographics
NPI:1831075654
Name:DSOUZA, COLETTE AGNES PERPETUAL
Entity type:Individual
Prefix:
First Name:COLETTE
Middle Name:AGNES PERPETUAL
Last Name:DSOUZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12400 N TATUM BLVD UNIT 5089
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-0046
Mailing Address - Country:US
Mailing Address - Phone:714-732-7890
Mailing Address - Fax:
Practice Address - Street 1:1703 W BETHANY HOME RD STE C3
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-7066
Practice Address - Country:US
Practice Address - Phone:602-944-2444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-15
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-002904152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist