Provider Demographics
NPI:1154311496
Name:VARGHESE, KOSHY K (MD)
Entity Type:Individual
Prefix:DR
First Name:KOSHY
Middle Name:K
Last Name:VARGHESE
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 1:645 COUNTY ROAD 262
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-1970
Mailing Address - Country:US
Mailing Address - Phone:512-508-2711
Mailing Address - Fax:512-869-8648
Practice Address - Street 1:7800 SHOAL CREEK BLVD STE 130W
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78757-1040
Practice Address - Country:US
Practice Address - Phone:512-407-8880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6732207P00000X, 207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG88679Medicare UPIN