Provider Demographics
NPI:1033601844
Name:KASANAGOTTU, KOUSHIK (MD)
Entity Type:Individual
Prefix:
First Name:KOUSHIK
Middle Name:
Last Name:KASANAGOTTU
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 1:13179 BROKERS TIP LN
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-0968
Mailing Address - Country:US
Mailing Address - Phone:901-834-8430
Mailing Address - Fax:
Practice Address - Street 1:1700 N WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5115
Practice Address - Country:US
Practice Address - Phone:909-883-8611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA287694207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program