Provider Demographics
NPI:1366548547
Name:GOSWAMI, SUSHANTA K (MD)
Entity type:Individual
Prefix:
First Name:SUSHANTA
Middle Name:K
Last Name:GOSWAMI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5002 COWHORN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-9766
Mailing Address - Country:US
Mailing Address - Phone:903-614-3000
Mailing Address - Fax:903-614-3525
Practice Address - Street 1:85 IH 10 N STE 112
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707-2560
Practice Address - Country:US
Practice Address - Phone:409-239-5139
Practice Address - Fax:409-730-8055
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00038023207R00000X
TXR30091207RN0300X
OKMD27500207RN0300X
TXR3091207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0170996OtherL & I
WA8290819Medicaid
WA8902519OtherCRIME VICTIMS
WAP00049522OtherRAILROAD
WAG8853731Medicare PIN
WAGAB37232Medicare PIN
WA0170996OtherL & I
WA8902519OtherCRIME VICTIMS
WA8290819Medicaid