Basic Information
| Provider Information | |||||||||
| NPI: | 1699892059 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NAG | ||||||||
| FirstName: | KOUSHIK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3815 E BELL RD STE 2200 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850322139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026333848 | ||||||||
| FaxNumber: | 6026333841 | ||||||||
| Practice Location | |||||||||
| Address1: | 10815 W MCDOWELL RD | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | AVONDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853925007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6234330202 | ||||||||
| FaxNumber: | 6234330204 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2007 | ||||||||
| LastUpdateDate: | 04/29/2019 | ||||||||
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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 | 207RI0011X | 005149 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 441542 | 05 | AZ | MEDICAID |