Basic Information
Provider Information | |||||||||
NPI: | 1467534701 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOSWAMI | ||||||||
FirstName: | NILESH | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 844658 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752844658 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9796913300 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 50 HILLCREST MEDICAL BLVD STE 102 | ||||||||
Address2: | SUITE 303 | ||||||||
City: | WACO | ||||||||
State: | TX | ||||||||
PostalCode: | 76712 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2542020480 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/19/2006 | ||||||||
LastUpdateDate: | 03/22/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | T3088 | TX | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
ID | Type | State | Issuer | Description | 00034820 | 01 | IL | RAILROAD | OTHER | 036096552 | 05 | IL |   | MEDICAID |