Basic Information
| Provider Information | |||||||||
| NPI: | 1104828300 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOYAL | ||||||||
| FirstName: | AMIT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1530 NEEDMORE RD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454143969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372774274 | ||||||||
| FaxNumber: | 9372778476 | ||||||||
| Practice Location | |||||||||
| Address1: | 1530 NEEDMORE RD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454143969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372774274 | ||||||||
| FaxNumber: | 9372778476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 11/14/2013 | ||||||||
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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 | 174400000X | 35-06-3153 | OH | N | Other Service Providers | Specialist | 207RI0011X | 35-06-3153 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | 35-06-3153 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 0857381 | 05 | OH | MEDICAID |