Provider Demographics
NPI:1972816932
Name:KOUSHIK, GEETHA (MD)
Entity type:Individual
Prefix:
First Name:GEETHA
Middle Name:
Last Name:KOUSHIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CANAL LANDING BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-5107
Mailing Address - Country:US
Mailing Address - Phone:585-368-4050
Mailing Address - Fax:585-723-6705
Practice Address - Street 1:105 CANAL LANDING BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-5107
Practice Address - Country:US
Practice Address - Phone:585-368-4050
Practice Address - Fax:585-723-6705
Is Sole Proprietor?:No
Enumeration Date:2010-07-20
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY272485207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03712609Medicaid
NY03712609Medicaid
NYJ400107048/GRPBA0017Medicare PIN